Damage Control

Management in the
Polytrauma Patient

Second Edition

Hans-Christoph Pape
Andrew B. Peitzman
Michael F. Rotondo
Peter V. Giannoudis
Editors

123
Damage Control Management in the
Polytrauma Patient
Hans-Christoph Pape
Andrew B. Peitzman
Michael F. Rotondo
Peter V. Giannoudis
Editors

Damage Control
Management in the
Polytrauma Patient
Second Edition
Editors
Hans-Christoph Pape Michael F. Rotondo
Department of Trauma Department of Surgery
Zurich University Division of Acute Care Surgery
Zurich University of Rochester, Medical Center
Switzerland Rochester, NY
USA
Andrew B. Peitzman
Division of General Surgery Peter V. Giannoudis
University of Pittsburgh Department of Academic Trauma &
School of Medicine Orthopaedics
Pittsburgh, PA University of Leeds
USA Leeds, West Yorkshire
United Kingdom

ISBN 978-3-319-52427-6    ISBN 978-3-319-52429-0 (eBook)

DOI 10.1007/978-3-319-52429-0

Library of Congress Control Number: 2017935020

© Springer International Publishing AG 2017

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Foreword by C.W. Schwab

The value of damage control surgical approach will only continue to increase in
importance within the context of casualty care as the complexity of intentional
injury continues to escalate in both the civilian and military environments.
Brian Eastridge MD, FACS
Out of the Crucible.1

Throughout the history of medicine, physicians and surgeons have been

forced to react with unconventional approaches to massive anatomic destruc-
tion and rapid physiologic depletion. To prevent death, they invented, inno-
vated, and forged solutions. This “forced empiricism” is a unique characteristic
of the surgery for trauma and, over time, has improved man’s ability to sur-
vive physical trauma.2
The benefits of damage control in both the military and civilian sectors
have been validated over the last 15 years. The term “damage control” was
initially adapted to surgery to describe a three-staged approach to exsangui-
nating abdominal injury by using a truncated laparotomy for bleeding and
contamination control. Its utility in response to the American urban gun vio-
lence epidemic of the 1990s resulted in improved survival. At the same time,
it resulted in serious complications like abdominal compartment syndrome
and the prolonged “open abdomen.” These, in turn, precipitated novel man-
agement schemes and innovations in critical care and forged groundbreaking
surgical techniques. During this same period, many young surgeons training
in our busy intercity trauma centers learned the principles of damage control
surgery and later, as military surgeons, applied the concepts to critically
wounded soldiers in Iraq. The DC approach was expanded to orthopedic,
vascular, thoracic, and neurologic surgery with the development of tech-
niques to swiftly control bleeding, relieve compartment pressure, and rees-
tablish profusion and afford skeletal stabilization. On these same battlefields,
an improved understanding of resuscitation and the need to reverse coagu-
lopathy led to the use of early whole blood, component therapy, and proco-
agulants as an effective prototype of promoting hemostasis and oxygen

1 
Out of the Crucible, Capt. Eric Elster and Dr. Arthur L. Kellermann (editors), published
by The Borden Institute, Washington, DC (in press).
2 
A national trauma care system: integrating military and civilian trauma systems to achieve
zero preventable deaths after injury. Washington, DC: The National Academies Press doi:
1.0.17226/23511.

v
vi Foreword by C.W. Schwab

delivery – damage control resuscitation. By combining damage control sur-

gery and damage control resuscitation, the allied military medical teams
reported unprecedented survival with wounding patterns that historically had
been mortal.
Several other important concepts emerged from Iraq and Afghanistan.
Damage control applied in mass casualty events in these austere environ-
ments was verified as an approach to match limited human and material
resources with the critical needs of a maximum number of wounded soldiers.3
Damage control management was adapted to the worldwide military trauma
system where minimal acceptable care delivered at intervals across geo-
graphically separated medical units was established and ingrained in the fab-
ric of military medicine. Individual patient care was supplemented with video
feedback between forward surgeons, critical care transport medical teams,
and reconstructive surgeons across the globe and led to standardized
approaches and improved outcomes. As the formal war period was winding
down, these broader concepts of military damage control translated to the
civilian sector and proved their value in Boston, San Bernardino, and Orlando.
Frequent mass casualty events from active shooters and explosive devices
are increasing and appear almost as daily events in our world. Suddenly, our
emergency systems and hospitals provide the safety net for dozens of patients
with wounds more commonly seen in combat than in civilian life. Thus, there
is an imperative that all medical personnel be expert in the use of damage
control for an individual patient and as an effective mass casualty and disaster
management process.
The second edition of Damage Control Management in the Polytrauma
Patient benefits from editors who are experts in the concepts and techniques
of damage control. The flow of knowledge between the disciplines of trauma
orthopedics and surgery and integration of the military and civilian experi-
ences provide critical information that is new, uniquely broad, and rare to find
in a single compendium. The selected topics are contemporary, relevant, and
contributed by military and civilian authors who have applied and verified the
uses of damage control in orthopedics, trauma, and emergency surgery. Thus,
in my opinion, this edition will be required reading for all who provide the
medical readiness to protect human life.
C. William Schwab, MD, FACS
Professor of Surgery
Perelman School of Medicine
University of Pennsylvania
Philadelphia, PA, USA

Remick KN, Shackelford SA, Oh JS, Seery J, Grabo D, Chovanes J, et al. Adapting essen-
3 

tial military surgical lessons for the home front. AmJDisaster Medicine (in press).
Preface by P.M. Rommens on behalf of the
European Society for Trauma and
Emergency Surgery (ESTES)

The second edition of the book Damage Control Management in the

Polytrauma Patient, edited by Pape, Peitzman, Rotondo, and Giannoudis, is a
milestone publication for the European surgical community. It answers to a
real need for modern, high-quality trauma care in most European countries.
Thanks to many new member countries, the European Union (EU) has
grown rapidly during the last decades. The unification process is a complex
task and will go on for several more generations. Harmonization of medical
care – for us of special interest is the care of the emergency surgical patient – is
one of many topics on the to-do list of the EU. Looking at incidence of acci-
dents, organization of trauma care and mortality after trauma in the member
countries of the EU, we are confronted with most diverse facts and figures.
Quality of road infrastructure, of motorcycles and motorcars, and density of
population are very different from country to country. Prevention of accidents
by limit of speed, obligation to wear a helmet or security belt, restriction of
alcohol consumption, and the implementation of these regulations by intense
control is also very variable. Due to continuing industrial and social develop-
ment, the number of motorcycles and motorcars has grown quickly. The
consequence is that the incidence of heavy traffic accidents is still raising and
the polytrauma patient continues to be sad and daily reality.
In contrast with this, regional organization of trauma care, establishment
of trauma centers, basic and postgraduate training of medical and paramedi-
cal staff involved in trauma care have not evolved parallel with the increasing
challenge.
The European Society for Trauma and Emergency Surgery (ESTES) is an
umbrella organization of national societies of trauma and/or emergency
surgery. Thirty-two European societies are institutional members and more
than 500 surgeons are individual members. The vision of ESTES is enhanc-
ing and harmonizing the care of the critical ill surgical patient. Different sec-
tions have been founded to realize these goals: skeletal trauma and sports
medicine, visceral trauma, disaster and military surgery, emergency surgery,
and polytrauma. The last section is a compilation of the most important
European guidelines on primary and secondary care of the severely injured.
This publication is an important instrument for all medical and paramedical
care providers, who are involved in the management of the polytrauma
patient. It gives a comprehensive overview of modern organization and
evidence-based principles of care of the severely injured. Several eminent
ESTES members have contributed as chapter editors. We therefore are very

vii
viii Preface by P.M. Rommens on behalf of the European Society for Trauma and Emergency Surgery (ESTES)

happy to endorse this publication with our logo and recommend it to a

European readership of emergency physicians, anesthetists, general surgeons,
(orthopedic) trauma surgeons, and rehabilitation staff. We very much hope
that this work will be accepted as a guide for treatment in the different set-
tings of trauma care all over Europe. With these different realities, we should
not overlook our common and unique goals of treatment: the polytrauma
patient should survive, independent of the country, the place and the time of
his/her accident, he or she should suffer the least morbidity, and have the best
rehabilitation and recovery possible. This book gives theoretical background
as well as practical evidence for good polytrauma care. We congratulate the
editors to this initiative, also, ESTES is grateful for being involved in sharing
their knowledge and wish the second edition of the book Damage Control
Management in the Polytrauma Patient good acceptance and distribution.

Prof. Dr. Dr. h. c. Pol M. Rommens

ESTES Secretary-General
Contents

Part I  Introduction: Pathophysiology

1 The Evolution of Trauma Systems . . . . . . . . . . . . . . . . . . . . . . . . . .  3
Robert J. Winchell
2 The Concept of Damage Control. . . . . . . . . . . . . . . . . . . . . . . . . . .  19
Claudia E. Goettler, Peter V. Giannoudis,
and Michael F. Rotondo
3 Changing Epidemiology of Polytrauma. . . . . . . . . . . . . . . . . . . . .  27
Fiona Lecky, Omar Bouamra, and Maralyn Woodford
4 Response to Major Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   33
Todd W. Costantini and Raul Coimbra
5 Defining the Lethal Triad. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   41
Mitchell Dyer and Matthew D. Neal
Part II  General Treatment Principles
6 Damage Control Resuscitation . . . . . . . . . . . . . . . . . . . . . . . . . . . .   57
Eric J. Voiglio, Bertrand Prunet, Nicolas Prat,
and Jean-Stéphane David
7 Head Injury. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   71
James M. Schuster and Philip F. Stahel
8 Chest Trauma: Classification and Influence
on the General Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   79
Frank Hildebrand, Hagen Andruszkow,
and Hans-Christoph Pape
9 Abdominal Compartment Syndrome. . . . . . . . . . . . . . . . . . . . . . .  97
Rao R. Ivatury
10 Orthopaedic Surgery Approach to Damage Control:
Decision-­Making and Indications. . . . . . . . . . . . . . . . . . . . . . . . .  107
Marius Keel and Hans-Christoph Pape
11 General Surgery Approach to DC: Decision Making
and Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  111
Molly Deane and Jose J. Diaz Jr

ix
x Contents

12 New Technologies for Vascular Injuries

and Hemorrhage Control. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  117
Megan L. Brenner and Thomas M. Scalea
Part III  Phases of Damage Control
13 Prehospital Damage Control. . . . . . . . . . . . . . . . . . . . . . . . . . . . .  133
Eileen M. Bulger
14 Phase I: Abbreviated Surgery (General Surgery). . . . . . . . . . . .   143
Brian P. Smith and Patrick M. Reilly
15 Abbreviated Surgery: Orthopaedic Surgery . . . . . . . . . . . . . . . .   159
Roman Pfeifer, Kai Sprengel, and Hans-Christoph Pape
16 ICU Care Following Damage Control Surgery . . . . . . . . . . . . . .  169
Constance W. Lee, Phillip A. Efron, and Frederick A. Moore
17 Damage Control Phase III: Repair of All Injuries,
General Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  179
Babak Sarani and Patrick Maluso
18 Phase III: Second Operation: Repair of All Injuries,
Orthopedic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  187
Hans-Christoph Pape and P. Giannoudis
19 Phase IV: Late Reconstruction, Plastic
Surgery for Orthopedics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  195
LCDR Scott M. Tintle and L. Scott Levin
20 Phase IV: Late Reconstruction – Abdominal/Chest
Wall Closure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  207
Whitney M. Guerrero and Timothy C. Fabian
Part IV  Special Circumstances and Outcomes
21 Principles of Damage Control for Pelvic Ring Injuries. . . . . . . .  219
P.V. Giannoudis and Hans-Christoph Pape
22 Principles of Damage Control for Pediatric Trauma. . . . . . . . . .  233
Christine M. Leeper, Andrew Peitzman, and Barbara A. Gaines
23 Principles of Damage Control in the Elderly. . . . . . . . . . . . . . . .  249
Pol Maria Rommens and Sebastian Kuhn
24 Damage Control in Vascular Injury. . . . . . . . . . . . . . . . . . . . . . .  263
L.P.H. Leenen
25 Principles for Damage Control in Military Casualties . . . . . . . .  273
John B. Holcomb and Thomas A. Mitchell
26 Penetrating Injuries and Damage Control Surgery:
Considerations and Treatment Options. . . . . . . . . . . . . . . . . . . .  283
Oscar J.F. van Waes and Michael H.J. Verhofstad
Contents xi

27 Complications After Damage Control Surgery:

Pin-Tract Infection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  297
Peter V. Giannoudis and Paul Harwood
28 Complications Status Post Damage Control
for the General Surgeon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  309
Anastasia Kunac and David H. Livingston
29 DC2 Outcomes of Damage Control Surgery: General . . . . . . . .  319
Ben Kautza and Jason Sperry
30 Late Outcome After Severe Fractures . . . . . . . . . . . . . . . . . . . . .  325
Roman Pfeifer and Christian Fang
Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  333
 Part I
Introduction: Pathophysiology
 The Evolution of Trauma Systems
1
Robert J. Winchell

1.1 Introduction nonexistent. This lack of policy-level response is not

universal. By comparison, the 2014 West African
By any measure, injury is a serious public health Ebola outbreak drew tremendous headlines and pro-
problem. Worldwide, road traffic injuries are the duced a massive public health response worldwide,
leading cause of death among the young (aged despite accounting for only about 23,000 identified
15–29 years), responsible for over a million deaths cases and about 9,800 deaths worldwide in its first
per year [1]. In the United States, unintentional year, according to CDC statistics [5] (Fig. 1.2). Over
injury is the leading cause of death for persons under 50 years after Accidental Death and Disability: The
the age of 45 years and is among the top ten causes Neglected Disease of Modern Society [6] was pub-
of death for all decades of life [2], a pattern that has lished by the National Academy of Science, injury
not changed significantly in decades (Fig. 1.1). remains the “neglected epidemic [6]” of modern
Overall, injury is responsible for almost a third of all society.
years of potential life lost. Moreover, it is a substan- When Accidental Death and Disability was
tial economic burden [3]. In real numbers, highway published in 1966, the field of injury care con-
transportation-related events in the United States sisted of largely disconnected elements: ambu-
were responsible for about 2.2 million injuries and lance services, emergency departments, intensive
33,000 deaths in 2010 [4]. And yet, there is no care units, and trauma research units. The report
focused public health policy at the federal level to established the foundational and seminal ele-
address the problem of injury in a systematic fash- ments of what has come to be recognized as a
ion. Moreover, state and regional approaches are trauma system, recommending measures to
­nonuniform, ranging from the very robust to the address the entire spectrum of injury including
epidemiology, prehospital care, definitive care,
rehabilitation, research, and injury prevention.
R.J. Winchell, MD, FACS Significant progress has been made in these indi-
Division of Trauma, Burns, Acute and Critical Care, vidual areas, including the evolution of the
Department of Surgery, Weill Cornell Medicine,
Emergency Medical Services (EMS) system,
New York, NY, USA
establishment of national standards for trauma
Trauma Center, New York-Presbyterian Weill Cornell
centers, dramatic improvements in automobile
Medical Center, New York, NY, USA
safety, as well as a greatly expanded base of
Trauma Systems Evaluation and Planning
­scientific knowledge in the areas of injury, shock,
Committee, American College of Surgeons
Committee on Trauma, Chicago, IL, USA and resuscitation. The Injury Prevention and
e-mail: rwinchell@me.com Control Center was established within the

© Springer International Publishing AG 2017 3

H.-C. Pape et al. (eds.), Damage Control Management in the Polytrauma Patient,
DOI 10.1007/978-3-319-52429-0_1
4 R.J. Winchell

Age Groups
Rank <1 1-4 5-9 10-14 15-24 25-34 35-44 45-54 55-64 65+ All Ages
Congenital Unintentional Unintentional Unintentional Unintentional Unintentional Unintentional Malignant Malignant Heart Heart
Anomalies Injury Injury Injury Injury Injury Injury Neoplasms Neoplasms Disease Disease
1 4,758 1,316 746 775 11,619 16,209 15,354 46,185 113,324 488,156 611,105

Short Congenital Malignant Malignant Malignant Heart Heart Malignant Malignant

Suicida Suicida Neoplasms Neoplasms
Cestation Anomalies Neoplasms Neoplasms Neoplasms Disease Disease
2 4,878 6,348 407,558 584,881
4,202 476 447 448 11,349 35,167 72,568
Maternal Chronic Low- Chronic Low-
Congenital Heart Unintentional Unintentional
Pregnancy Homicida Suicida Homicide Homicide Respiratory Respiratory
Anomalies Disease Injury Injury
3 Comp. 337 386 4,329 4,236 Disease Disease
179 10,341 20,357 17,057
1,595 127,194 149,205
Chronic Low-
Malignant Congenital Malignant Malignant Liver Cerebro- Unintentional
SIDS Homicida Suicide Respiratory
Neoplasms Anomalies Neoplasms Neoplasms Disease vascular Injury
4 1,563 125 6,551 Disease
328 161 1,496 3,673 8,785 109,602 130,557
15,942
Chronic Low-
Unintentional Heart Heart Heart Diabetes Alzheimer’s Cerebro-
Respiratory Homicida Homicide Suicide
Injury Disease Disease Disease Mellitus Disease vascular
5 1,156 169
Disease
75
152
941 3,258
2,581 8,621
13,061 83,786 128,978

Placenta
Influenza Heart Heart Congenital Diabetes Liver Diabetes Liver Diabetes Alzheimer’s
Cord
& Pneumonia Disease Disease Anomalies Mellitus Disease Mellitus Disease Mellitus Disease
6 Membranes
102 73 100 362 684 2,491 5,899 11,951 53,751 84,767
953
Chronic Low- Chronic Low-
Bacterial Influenza Influenza Liver Diabetes Cerebro- Cerebro- Influenza Diabetes
Respiratory Respiratory
Sepsis & Pneumonia & Pneumonia Disease Mellitus vascular vascular & Pneumonia Mellitus
7 578
Disease
67
Disease
197 676 1,952 5,425 11,364 48,031 75,578
64 80
Chronic Low-
Respiratory Cerebro- Influenza Diabetes Cerebro- Unintentional Influenza
Septicemia HIV Respiratory Suicide
Distress vascular & Pneumonia Mellitus vascular Injury & Pneumonia
8 522
53
41 61 193
631
1,687
Disease 7,135
45,942 56,979
4,619
Circulatory
Benign Cerebro- Complicated Cerebro-
System Septicemia HIV Septicemia Septicemia Nephritis Nephritis
Neoplasms vascular Pregnancy vascular
9 Disease
47
35
48 178 508
1,246 2,445 5,345 39,080 47,112
458
Chronic Low-
Neonatal Perinatal Benign Benign Influenza Influenza
Respiratory HIV Nephritis Septicemia Suicide
Hemorrhage Period Neoplasms Neoplasms & Pneumonia & Pneumonia
10 389 45 34 31
Disease
449 881
2,378 4,947 28,815 41,149
155

Fig. 1.1  Leading causes of death in the United States, 2013 (Source: CDC WISQARS. http://webappa.cdc.gov/sas-
web/ncipc/leadcaus10_us.html)

Deaths per Year the degree to which state and local government
6
(in millions) has been inspired to address the problem and the
extent to which volunteer efforts by engaged sys-
5
tem stakeholders can drive improvement.
4 The sections that follow trace the historical
3 evolution of the approach to injury care within
2 the context of changing socioeconomic circum-
stances, the emergence of a set of essential ele-
1
ments that define a trauma system, and the
0 integration of these elements into a functional
Injury HIV/AIDs/ TB, Malaria Ebola
design. The legislative and structural challenges
Fig. 1.2  The relative impact of injury [5, 46] to effective implementation of trauma systems
will be discussed, and strategies of successful
Centers for Disease Control and Prevention in models will be explored with the objective of
1985. These advances have been associated with framing future efforts to expand the coverage of
substantially lower death rates from injury over trauma systems throughout the nation.
the last 30 years (Fig. 1.3). Though there is sig-
nificant evidence to demonstrate that coordina-
tion of these individual elements into a 1.2 The Process of Evolution
comprehensive system of trauma care leads to
improved outcomes after injury [7–15], these In the current age of highly technical and
data have not led to a broad implementation of institution-­based medical care, it is worth looking
trauma systems across the country [16, 17]. At back to realize that it has not always been this
the present time, systems for the provision of way. At the start of the twentieth century, only a
injury care remain a patchwork, dependent upon bit more than 100 years ago, the majority of
1  The Evolution of Trauma Systems 5

Fig. 1.3  Age-adjusted case 25

fatality rate from motor
vehicle incidents (Source:
CDC WISQARS. http://
www.cdc.gov/injury/
20
wisqars/fatal_injury_

Age-Adjusted Case Fatality Rate

reports.html)

15

10

0
1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

2003

2005

2007

2009

2011

2013
health care was delivered in the home. Large itself often carried a great risk of death through
­hospitals existed primarily for the care of the infectious complications. Only with the rise of
indigent or casualties of war, a state of affairs that the Lister’s antisepsis, the bacterial theory of dis-
dated back to antiquity. Outside of the military, ease, and the expansion of surgical capabilities
these hospitals were usually established and that followed did the balance shift. Hospitals
operated as private charities or as elements of began to take their current form as places that
social infrastructure funded through local gov- offer highly technical therapies well beyond what
ernment to care for the poor.1 There was often could be accomplished in the home and as places
little differentiation between the care of the sick that offered the potential to cure.
and the housing of the poor and indigent, and Even though the development of the hospital
many hospital facilities served both purposes. In was well under way in the early decades of the
either case, these facilities were places to be twentieth century, the concept of the modern
avoided by those with the means to do so. The trauma center is much newer. Through the 1950s,
sick and injured were cared for at home by their hospitals and hospital care were defined by the
family, and “no gentleman…would have found conquering of infectious diseases, the evolution
himself in a hospital unless stricken by insanity of modern surgical techniques, and the progres-
or felled by epidemic or accident in a strange sive interdependence of the hospital and the
city” [18]. Based upon the care available and the academy of medicine, including training and
associated high mortality, this conception of hos- research. In both the historical and the practical
pital care was well founded. Prior to the late nine- literature on hospital development from the mid-­
teenth century, medicine had little to offer by way twentieth century, the care of the injured is a
of curative therapy, and the hospital environment passing comment, if it is mentioned at all. Only
since the late 1980s, with the development of
national standards and the Trauma Center
In fact, prior to the advent of Social Security in the 1930s,
1 
Verification program of the American College of
the provision of aid to needy populations was felt to be
completely outside the Constitutional mandate of the Surgeons Committee on Trauma, has the idea
Federal government. of the modern trauma center become firmly
6 R.J. Winchell

e­ stablished as a highly sophisticated institution a­dmission to a hospital. The decision to admit

that is focused on improving injury care through was often made by the hospital board and
clinical excellence, teaching, and research. weighed many factors beyond need for medical
The first hospitals to embody the concept that care [18]. Not all types of illness were admitted
care of the injured should be an area of specialty for treatment, nor were all socioeconomic groups.
and focus, recognizing the importance of this idea Even into the middle of the twentieth century, the
in improving outcomes, arose in the 1960s. Their mission of the hospital to care for certain dis-
roots were firmly in the traditional past of the pub- eases, including contagion and mental illness,
lic hospital. These hospitals were a refuge for the was a topic of debate [23]. Patients presented
indigent sick by intent and the injured by neces- themselves to the hospital either under their own
sity. They were also at the heart of medical educa- power or with the assistance of friends and fam-
tion and research. Two hospitals among the first ily. The first hospital-based ambulance system in
with organized trauma services were the Cook the United States, providing a vehicle and a
County Hospital [19] and San Francisco General trained attendant to be summoned to transport
Hospital, but the public hospitals in many US cit- patients to the hospital for care, was established
ies also functioned increasingly as centers for the by Bellevue Hospital, in New York City, in 1869.
care of the injured. Over the next decade, an The system began with two horse-drawn vehi-
expanding number of such facilities became cles, which were to be kept “in good order and fit
known for their hard-earned trauma expertise. for service at all times,” and presaged modern
Initially the hospitals that could claim the title of regulations regarding ambulance equipment lists
“trauma center” were almost exclusively located by requiring that a box be kept beneath the driv-
in large urban areas with high rates of poverty and er’s seat containing among other things a quart
violence. Outside the sphere of influence of these flask of brandy and two tourniquets [24].
centers, injury care remained haphazard, under- Ambulance systems soon appeared in other major
taken in the facility that happened to be the closest cities, transitioning from horse to internal com-
and by the practitioner who happened to be avail- bustion engine in the early twentieth century.
able. Injury care was largely a matter of chance, a These systems focused primarily on getting the
situation that persisted well into the 1970s, and, it patient to the hospital rather than initiating care
might be argued, persists to the present day. These and did not evolve far beyond the provision of the
chances could be improved if the patient, or those most basic prehospital care until much later.
bringing the patient to the hospital, had the knowl- For the next 100 years, through the 1950s and
edge of the receiving hospital’s capabilities and 1960s, there was also little evolution in the stan-
the ability to choose their destination. The princi- dards regarding ambulance equipment or training
ple that injured patients fared better at a hospital of attendants. Because the focus of ambulances
experienced in trauma care was initially based remained primarily that of transporting bodies,
upon the experience of the providers of direct vehicles were designed for use interchangeably
patient care but has subsequently been upheld by as ambulances and hearses, and mortuaries often
objective data [20–22]. The fact that all hospitals functioned as ambulance agencies due to the
are not created equal in terms of care of the injured interoperability of the vehicles. The principle that
has been well established, and it follows that one a modern network of Emergency Medical
key element of establishing a system to improve Services (EMS), with the expectation that prop-
care after injury is the ability to identify hospitals erly equipped vehicles, manned by medically
with the commitment to care for the injured and to trained staff, would respond within minutes of a
verify their capabilities. call as an essential public service, arose from rec-
The next logical step in the process is to ommendations made in the 1966 white paper
­establish a way to ensure that injured patients Accidental Death and Disability and from the
are treated at the appropriate trauma center. provisions of the Highway Safety Act of 1966
Historically, patients literally applied for [25], which was enacted later the same year. This
1  The Evolution of Trauma Systems 7

act included provisions for funding as well as ments of trauma system design, including the
requirements that states take action or face penal- concept of an administrative lead agency to gov-
ties. Implementation was further accelerated by ern system operations, the identification of differ-
the passage of the 1973 Emergency Medical ent levels of trauma hospital capability, the
Services Systems Act [26], which established integration of EMS, and the role of process
guidelines and provided funding for regional improvement. The first operational statewide
EMS development. With this stimulus, EMS sys- trauma system was created with the establish-
tems rapidly developed and matured during the ment of the Maryland Institute for Emergency
next 25 years of the twentieth century, coincident Medicine in 1973. The small size of the state of
with the differentiation of hospitals into trauma Maryland allowed for implementation of a sys-
centers. Combined with the recent wartime expe- tem in which all severely injured patients within
rience in Korea and Vietnam, which clearly dem- the state were transported by air to a single dedi-
onstrated the advantages of rapid evacuation and cated trauma facility. In the years that followed,
early definitive treatment of casualties [27], it similar efforts were made to establish coopera-
became increasingly apparent that coordination tive networks of trauma centers that were con-
of field treatment and transportation to ensure nected by a coordinated EMS system and linked
that injured patients arrived at a capable trauma by shared quality improvement processes. These
care facility was of critical importance, and the efforts were driven both by the Vietnam experi-
conception of a trauma system, as opposed to an ence and by the finding that a large proportion of
isolated trauma center, began to evolve. deaths after injury in non-trauma hospitals were
Initially, the concept of a trauma system was due to injuries that could potentially have been
centered upon the large urban trauma centers, better managed and controlled [29]. The imple-
which established standards and protocols within mentation of such systems led to dramatic
their region, promulgated through their own EMS decreases in what was perceived to be “prevent-
systems or through their relationship with EMS able death,” [7] as well as overall improvements
providers in the region. For hospitals with their in post-injury outcomes that were duplicated in
own large EMS, or those with clearly pre-­existing widely varying geographic settings. Following
roles in the community, the destination hospital the models established in Illinois and Maryland,
was preordained. It was common knowledge that these regional systems were founded upon the
serious injured patients were best cared for at the premise that all critically injured patients should
trauma center, even though there were no estab- be transported to a trauma center and that other
lished rules or regulations directing the flow of acute care facilities within a region would be
ambulance traffic. The growing knowledge that bypassed. Based upon the “exclusion” of non-­
outcomes for seriously injured patients were bet- designated hospitals from the care of the severely
ter in hospitals that had the experience and injured, this approach is frequently referred to as
resources to care for them, combined with an the exclusive model of trauma system design.
increasing perception of the element of chance The exclusive model works well in urban and
involved in unregulated choice of ambulance des- suburban settings, where there are sufficient
tination, led to the first efforts to coordinate the trauma centers to provide access and to care for
prehospital system to transport injured patients the expected number of injuries. Though often
with the dedicated facilities that provided defini- described as a regional system, an exclusive sys-
tive care. tem functions as a funnel, not a network, and it
Drawing on the experience at the Cook County does not utilize, let alone maximize, the resources
Hospital, the State of Illinois passed legislation of other health-care facilities within the region.
establishing a statewide coordinated network of This approach has the advantage of focusing
trauma centers in 1971 [28]. This statewide plan patient volume and experience at the high-level
identified many of the terminologies and con- centers and the disadvantage of leading to attenu-
cepts that would come to be considered key ele- ation of skills in non-designated centers, with
8 R.J. Winchell

resultant loss of flexibility and surge capacity. embraced a different paradigm: the inclusive
Paradoxically, because of the attrition of local model of trauma system design.
resources, the model may serve to decrease As the name suggests, the inclusive model
access to competent care in larger geographical involves the design of a system in which all
areas and in low-resource areas. In such circum- health-care facilities within a region are involved
stances, transport times to the trauma center may with the care of injured patients, at a level com-
be very long, especially in periods of inclement mensurate with their commitment, capabilities,
weather when aeromedical transport cannot be and resources. Ideally, through its regulations,
used. Moreover, the volume of injuries seen may rules, and interactions with EMS, the system
overtax the resources of the few available trauma functions to efficiently match an individual
centers, and the number and length of inter-­ patient’s needs with the most appropriate facility,
facility transfers may place a severe burden on based upon resources and proximity. Under this
EMS resources. The only way to increase the paradigm, the most severely injured would be
depth of coverage within an exclusive system is immediately recognized and either transported
to recruit or build additional trauma centers, directly or expeditiously transferred to the top-­
which can be both expensive and politically dif- level trauma care facilities. At the same time,
ficult, given the complex set of drivers that lead a there would be sufficient local resources and
hospital to undertake the significant commitment expertise to facilitate the optimal management of
to being a trauma center. the less severely injured, avoiding the risks and
The limitations of the exclusive model, and resource utilization incurred for transportation to
the difficulties in deploying the model on a large a high-level facility whose resources were not
scale, were experienced throughout the 1990s truly needed. The basic concepts of the inclusive
[30]. Despite evidence of the benefit of trauma model were described in the 1992 Model Trauma
systems, very few states and regions were able to System Care Plan [33] and refined in the 2006
establish a system as a matter of governmental Model Trauma Systems Planning and Evaluation
policy, and fewer still were able to fulfill a set of [34] document, both published by the Health
eight criteria that had been proposed as corner- Resources and Services Administration of the US
stones of exclusive system design [31]. This stag- Department of Health and Human Services.
nation in system development arose in part due to Consistent with the findings of the 1999 IOM
the difficulties inherent in extending the exclu- report, the 2006 Model Trauma Systems Planning
sive system model and from a lack of public sup- and Evaluation document places the previously
port for system finance and governing policy. In a identified elements of trauma system function
broader sense, exclusive systems often lacked a within an overarching public health framework,
truly integrative overarching structure that could emphasizing the need to integrate the entire spec-
tie together and build upon the significant gains trum of injury care, from prevention through
achieved by the individual components in the rehabilitation. The document also highlights the
trauma system universe. The 1999 Institute of importance of coalition building at the grassroots
Medicine report Reducing the Burden of Injury: level and of policy development and implementa-
Advancing Prevention and Treatment [32] helped tion at the governance level. The inclusive system
to open the aperture through which injury care model has been the primary guiding framework
was perceived and identified five broad areas of for systems development for the last 10 years.
focus for future development: improving coordi- Despite its relatively universal acceptance at
nation and collaboration between individual pro- the theoretical level, the inclusive model is often
grams, strengthening capacity for research and misconstrued and misapplied in practice, not as
practice, integrating the full spectrum the injury a system with global involvement of all facili-
field, nurturing public awareness and support, ties but as a voluntary system in which any hos-
and promoting informed policy making. In this pital that wishes to participate is included at
context, the thrust of trauma system development whatever level of participation they choose.
1  The Evolution of Trauma Systems 9

This approach fails to fulfill the primary goals 1.3 The New Era
of an inclusive trauma system that all resources
in the region are involved and to ensure that the The period of time from the 1980s through the
needs of the patient are the primary driver of early years of the twenty-first century saw the
resource utilization. An inclusive system does rise of the trauma center as a center of excellence,
mean that all hospitals must participate in the a place where injured patients had better care
system and be prepared to care for injured with demonstrably better outcomes, and the con-
patients at a level commensurate with their comitant understanding that with such differ-
resources and capacity, but it does not mean that ences in care, all injured patients deserved to be
hospitals are free to determine their level of par- treated at a trauma center. At the same time,
ticipation based upon their own perceived best major changes in health-care finance in the age of
interest. Objectively assessed, the needs of the managed care and managed competition
patient population served are the parameters increased the financial pressure on hospitals,
that should determine the apportionment and especially those caring for the most severely ill
utilization of system resources, including the patients and those patients with insufficient fund-
level and geographic distribution of trauma cen- ing. At a time when the system-based approaches
ters within the system. When this maxim is for- to trauma care were trying to grow, and there was
gotten, system function suffers, and problems of a need for more high-level trauma centers, the
either inadequate access or oversupply can economic pressures on hospitals made trauma
develop. care an undesirable mission, one that could lead
The implementation of a scheme for the distri- to financial ruin. The 1990s saw a rising tide of
bution of system resources that is based solely on trauma center closings and contractions, even
the needs of the patient population served can be involving some of the iconic public hospitals and
fraught with conflict. While the potential for such foundational trauma centers. One study reported
conflict exists at all levels of resource allocation, that while 60 trauma centers closed between
it is often most prominent involving decisions 1981 and 1991, over 300 closed between 1990
around trauma center designation because these and 2005 [35]. The same study identified that, not
decisions often carry heavy political and finan- surprisingly, financial pressures were one of the
cial consequences that extend well beyond mat- chief risk factors for trauma center closure.
ters of patient care. To heighten the challenge, The crisis atmosphere engendered by the real
these difficult policy implementation decisions and threatened loss of trauma care capacity led
are generally the responsibility of the lead agency many regions to develop methods of funding sup-
governing the system, which is most often a rela- port to assist trauma centers in their care mission.
tively underfunded state or regional agency. In In the first years of the twenty-first century, the
addition to lacking staff and resources, these decline of managed care and managed competi-
agencies are most often led by political appoin- tion, a nationwide decrease in levels of interper-
tees and government employees who do not stay sonal violence, and other changes in the climate
in a particular job for more than a few years at a of health-care finance combined to create a sea
time. These factors have the combined effect of change in the financial attractiveness of provid-
limiting both the stability of institutional direc- ing care for the injured in many geographic
tion and the ability of agency leaders to take a regions. Hospitals began to look upon the care of
strong stand in the face of opposition from large the injured population not as a burden to be
and well-funded health-care organizations. These shifted but as a potentially profitable line of busi-
challenges have proven the Achilles’ heel of ness to be actively sought after.
inclusive system development and have ham- Somewhere in the first 5 years of the twenty-­
pered their broad implementation, which first century, the balance of forces shifted to the
­continues to fall far short of a nationwide system point that the number of hospitals claiming
for the care of the injured. trauma center status was larger than the number
10 R.J. Winchell

of traditional trauma centers threatened with clo- “propagation,” carries with it a new set of chal-
sure. According to self-designation data col- lenges. These challenges cut to the very core of
lected annually by the American Hospital many unique elements that drive the social and
Association [36], in the year 2000, 258 (6.1%) of political philosophy of the United States and
hospitals reported having a level I trauma center. have clearly placed the determination of need for
In 2010 the number had risen to 387 (9.4%), and a new trauma center as much in the political
in 2013 there were 416 hospitals claiming level I arena as the scientific one. In the political climate
trauma center status. This data is concordant of the second decade of the twenty-first century,
with that collected by the Trauma Center governments have been generally unwilling to
Verification Review and Consultation program regulate free markets, including health care. Yet
of the American College of Surgeons Committee Adam Smith’s “invisible hand” of the market-
on Trauma, which reports a similar increase in place is not likely to provide wise guidance for
verified trauma centers, rising from 208 in 2005 the development of a sustainable network for the
to 430 in 2014, with level I centers rising from care of the injured, which is arguably a central
81 to 120 over the same period. This new eco- feature of the social structure. Recent history has
nomic climate, while having the benefit of demonstrated that changes in economic factors
increasing the number of participants in the can easily lead hospitals to exit the trauma “mar-
inclusive trauma system, has done so at the cost ket” regardless of the burden of injury within the
of a major redistribution in the way resources population and that the commoditization of
and patients are deployed. Not surprisingly, the trauma care has the potential to disrupt stable
largest number of new trauma centers arose not access to trauma care across the board. The cur-
in the major urban areas, which remain relatively rent debate over “trauma deserts” [38] identified
poor and where trauma center closings remain a in the city of Chicago, the most prominent of
concern, but in more affluent suburban areas. which has at its center a large and capable hospi-
These new centers can encircle the pre-existing tal that closed its trauma center in the late 1980s,
centers and decrease their patient volumes, as brings the issue of the potential conflict between
well as cutting into government incentives public service and economic performance into
intended to stabilize those pre-existing centers. sharp relief.
Increasingly, providing care for the population Ultimately, the model of the inclusive trauma
of patients suffering injuries as a result of motor system has been well developed, and there is sub-
vehicle crashes, falls, or other accidents could be stantial evidence to show the efficacy of these
a profitable undertaking, especially if the patients systems in improving outcomes after injury, but it
with the highest level of acuity could still be is undeniable that inclusive systems are difficult
transferred to larger traditional centers, avoiding to develop, finance, operate, and sustain. The sys-
the financial risks associated with handling com- tem has a scale and function that undeniably
plex cases, with associated high resource utiliza- places it in the realm of an essential element of
tion, under current strategies implemented to the public service sector, yet it operates primarily
control health-care costs. As a result, established within the private sector, the largely market-­
centers find themselves once again facing an driven world of health-care delivery. In most
unpredictable economic future, and decisions areas, the public health elements of the trauma
around the designation of new trauma centers in system are not well recognized and not well
many geographical areas have become increas- funded within the governmental bureaucracy of
ingly contentious. This trend may well result in the state or region. This infrastructure has been
decreased access to trauma center resources for increasingly challenged to find funding for many
highly vulnerable populations [37], despite other critical social elements, including the over-
larger overall numbers of centers. all provision of health care itself. If trauma sys-
This new era, in which the concern has shifted tem development is to proceed, these barriers
from trauma center closings to trauma center must be identified and overcome.
1  The Evolution of Trauma Systems 11

1.3.1 Optimal Design Elements assistance and funding to strengthen state capac-
ity while at the same time assuring “actions and
The functional development of trauma systems services that are in the public interest of the entire
has paralleled an evolving understanding of the nation [39].” This basic framework was further
problem of injury. Trauma centers and the coor- expanded by the 1994 Core Public Health
dinated EMS systems that bring patients to them Steering Committee into ten essential services,
began as a reactive element; trauma was seen as a represented graphically in relation to the three
sporadic event, an “accident” that could not be IOM core functions in Fig. 1.4. This framework
prevented or predicted. The best a system of care was applied, utilizing functional elements felt to
could do was to be very efficient in delivering be critical from experience in trauma systems, to
care to those affected. Early system advances create an injury-specific diagram of essential ser-
were logically driven by the frontline care pro- vices that was put forward in the Model Trauma
viders, whether in the field or the hospital, and Systems Planning and Evaluation document
resulted in substantial improvements in outcome (shown in Fig. 1.5). The public health structure is
for the injured. Increasing sophistication in the a good model to use for setting the structure and
acute care of the injured also highlighted the fact outlining what we need from a trauma system
that most injury mortality occurs at the scene, from a high-level strategic perspective. It is based
prior to any intervention, and can never be upon broad principles that are global in applica-
addressed by post-injury treatment, no matter tion and as a result provides a working frame-
how well optimized. This realization, as well as a work that is largely independent of specific
deepening body of research on the causes and circumstances.
mechanisms of injury, illustrated the need to The challenge of the public health model for
focus efforts on prevention of injury if further trauma system development, like the larger pub-
progress was to be made. lic health model from which it is derived, is that
This evolution of understanding is analogous it offers no tactical advice as to how the specific
to the course of historical progress made in the goals are to be achieved. Further, the high degree
treatment of epidemic diseases and the develop- of variability in geography, resource availability,
ment of modern public health systems, an obser- and political climate across the country requires
vation not lost on those involved with trauma that any such implementation be context depen-
system development. If injury is viewed not as a dent and thus tailored to specific local circum-
sporadic event but as an epidemic, it is a logical stances. There is no global approach or proven
next step to apply well-proven principles of pub- framework to assist in pulling the elements of a
lic health that have been so successful in the trauma system together. Further, the federal gov-
management of infectious epidemic diseases to ernment has not taken up the role outlined by the
the broader problem of injury. This concept was Institute of Medicine of assuring “actions and
at the heart of the 2006 Model Trauma Systems services that are in the public interest of the entire
Planning and Evaluation document, which nation.”
adopted the public health framework developed In this evolution to an expanded public health
by the CDC. model, the approach to trauma care has grown far
The CDC framework builds upon the 1988 beyond the frontline providers of emergency care
Institute of Medicine report The Future of Public and into a complex and interconnected entity that
Health [39], which proposed that there were touches on a large group of people distributed
three core functions of public health agencies: across many professions, some far removed from
assessment, policy development, and assurance. direct health care. This multidisciplinary and
The report placed the primary responsibility for integrative process brings together groups who
public health on the state. It recommended that approach the problem of injury in fundamentally
the federal government function to establish different ways, melding the epidemiologists, the
nationwide objectives and provide technical statisticians, and the regulators, all of whom
12 R.J. Winchell

Fig. 1.4  The CDC model of

Asse
public health: the ten ssm
en
essential functions and their t
relationship to the three goals
defined by the IOM [33]
MONITOR
HEALTH

EVALUATE DIAGNOSE &

INVESTIGATE
1
9 MANAGE 2
EM ME
ST
ENSURE

NT
SY
COMPETENT INFORM,
Assurance

WORKFORCE 8 3 EDUCATE,
RESEARCH EMPOWER
10

RE
ES

TU
7 EN 4 MOBILIZE

C
LINK TO TIA RU COMMUNITY
L IN F RAST
PROVIDE CARE PARTNERSHIPS
6 5

Po
li
ENFORCE DEVELOP

cy De
LAWS POLICIES

ve
lo
pm
en
t

Asse
ssm
en
t

PH: Monitor Health

TS: Injury Data PH: Diagnose &

PH: Evaluate Collection Investigate

TS: Evaluation TS: Gap Analysis

Surveillance
MANAGE
EM ME
PH: Ensure ST Leadership
PH: Inform,
NT
SY

Competent In
Educate, Empower
fo
ht

Workforce
Assurance

rm
Govt Oversig

ation Technolo

TS: Process Improvement

TS: Human Resources RESEARCH
and Education Program
10
ate

RE
St

gy

PH: Mobilize
ES

TU

PH: Link To EN Fin a n c e s

S

Community Partnerships
C

TIA RU
Provide Care L IN F RAST
TS: Trauma System
TS: Prehospital and Advisory Committee
Definitive Care
Po

PH: Enforce PH: Develop

lic

Laws
y

Policies
De
ve

TS: Rules/Regulations TS: Legislation lo

pm
en
t
Fig. 1.5  The public health
model of trauma system
design [33]
1  The Evolution of Trauma Systems 13

manage problems at a broad population level, degree to which frontline care providers become
with the clinicians and other providers in acute involved in the broader area of policy develop-
care and rehabilitation, who approach the prob- ment and implementation around the problem of
lem from the level of the individual patient. The injury across its full spectrum.
development and maintenance of such a coalition This differential in both funding and focus,
is a considerable project, as is the governance between the public health and direct patient care
and leadership necessary to ensure its longevity, sectors, is a major challenge to the cohesion of
sustainability, and success. These factors alone trauma systems. While trauma centers and EMS
would be sufficient to make trauma system devel- agencies deal in millions of dollars, most of
opment a long and arduous process. which are external to the governance of a trauma
The funding mechanisms for trauma systems system, the necessary elements of infrastructure
and trauma care are equally complex and in many that form the essential glue binding the system
cases work to make the problem of cooperative together are often sacrificed to lean governmental
system development event more difficult. budgets at the state level. Thus, in many systems,
Elements of the trauma system that address the the medical elements are fairly well developed at
larger population-based issues of epidemiology, the level of the individual center or small coop-
prevention, and governance have most frequently erative network, while development has stalled at
arisen from governmental agencies already work- the level of system integration, large-scale pre-
ing in more traditional public health arenas. vention, and quality assurance because there are
These agencies are often relatively poorly funded insufficient resources to carry out these large-­
and have been even more vulnerable in difficult scale system tasks on a daily basis. The situation
economic times. As a result, resources are chron- is perpetuated by a lack of public understanding
ically scarce, and efforts are often divided across of the need and resultant inability to mobilize
a number of different project areas. Further, the legislation that produces structural change. This
time frame for progress is on a longer scale and is the impasse that most regional trauma systems
considers data and trends longitudinally. Those face in the second decade of the twenty-first cen-
collecting and analyzing the data are often far tury. There are a few systems that have been able
removed from the front lines of patient care and to allocate and preserve the critical infrastructure
the individual patient perspective. Thus, the needed to administer the system and continue to
problem of injury has not often been uniformly grow, but most have not.
enough of a priority within the public heath
bureaucracy.
In contrast, direct patient care after injury is 1.4 Barriers to Implementation
funded through the health-care delivery system
and has been subject to the variations in the Given a general acceptance of the primary
health-care market, payer reform, and efforts ­elements that make up a trauma system, and the
toward cost containment. The expenditures are previously cited evidence of their effectiveness
generally orders of magnitude larger than those in improving the care of the injured, it is perplex-
seen for the more population-based functions and ing that trauma system development remains so
typically funded through a combination of haphazard and inconsistent, raising the question
­government benefits and private insurance. The of why trauma systems have not really caught on.
work in direct patient care follows a much shorter A significant component is undoubtedly the
time frame, as the episodes of care typically nature and perception of injury among the
extend over days and weeks, rather than years. ­general population and, even more importantly
Frontline providers work almost exclusively at for trauma system development, the role of
the level of the individual patient and rarely see ­post-injury care in modulating that risk. From a
the problem of injury framed in the context of psychological perspective, studies suggest that
population health or overall health-care costs. individual estimates of risk are inaccurate, tend-
This relatively narrow focus often limits the ing to overestimate more sensational and
14 R.J. Winchell

d­ ramatic causes [40], ­leading individuals to rate cal action. In the complex interplay of the political
the risks of injury lower than what they actually process, market forces, and patient needs, it has
are. Moreover, media coverage is highly influen- proven impossible for most regions to achieve
tial on societal perception of risk [41] and hence public policy support and significant stable fund-
supports for policies to reduce that risk [42, 43]. ing. Without these elements, systems struggle to
Media coverage that addresses injury is generally make consistent and lasting progress in trauma
focused on the event and its immediate after- system implementation beyond a level that can be
math, with relatively little coverage of the avail- sustained by the largely volunteer efforts of sys-
ability and impact of post-­ injury care or tem stakeholders who share the mission.
celebration of trauma survivors, in direct contrast The nature of health care, and particularly the
to disease entities such as cancer, in which the nature of injury care, presents a particularly dif-
opposite is generally true. These elements com- ficult challenge within the context of the socio-
bine to lessen public awareness of the personal economic structure of the United States.
risks of injury and impact of trauma care. Data A majority of US citizens will endorse the
show that over half of those surveyed did not concept of emergency care for the sick and
­
know that injury was the leading cause of death injured as a fundamental human necessity, and
in the first decades of life and that though the that the provision of such care is a vital function
public general supports the concept of trauma of society. This concept dates back to the found-
care, most believe it to be already in place [44]. ing principles for the original public hospitals
Another significant element in the complexity and gained increasing prominence in US policy
of trauma system development and implementa- through the mid-twentieth century, reaching a
tion lies in the multifaceted nature of trauma sys- peak with the establishment of the Medicare and
tems. By their very nature, trauma systems Medicaid programs in the 1960s. The momentum
involve a large number of people and agencies, was focused on the problem of road traffic acci-
each with their own focus and expertise and each dents during the Kennedy administration and car-
with unique and sometimes divergent culture, ried over to the care of the injured with the
objective, and focus. This reality puts the design publication of Accidental Death and Disability
and operation of a trauma system beyond the pur- and the subsequent burst of progress in EMS and
view of one single professional group or single trauma system development that it enabled.
sector of the trauma care spectrum; an effective The era of strong public support, and thus of
solution requires the creation and maintenance of federal support, came to an end in the last decades
a broad coalition. It further establishes the need of the twentieth century, as policy turned more
for a neutral governance process that can balance toward deregulation, limited government, and the
competing priorities while keeping the needs of culture of individual financial responsibility that
the population served as the guiding principle. characterized the 1980s and 1990s. In this set-
Finally, it can be argued that a system of care for ting, the model of the large publically financed
the injured, for that matter, a system of health care hospital providing care for those in need became
in general, is part of the essential network of pub- largely untenable, and most city and county gov-
lic services provided by government. These con- ernments have divested themselves of this
siderations place a large portion of trauma system responsibility or operate their health-care facili-
development firmly in the governmental, and ties on increasingly austere budgets. Private hos-
hence the political and legislative, arena. This is pitals have been forced to assume an increasing
especially true with decisions mediating complex share of the care for patients with little or no
issues of resource allocation, financial support, funding, while insurers have exerted intense
and governance. In this arena, scientific argu- downward pressure on payments. Health-care
ments alone are insufficient to make the case, and facilities have become increasingly competitive
the problem of injury has rarely held public atten- for patients with a funding source and face
tion in a way that has engendered decisive politi- increasing risk in providing care for those who do
1  The Evolution of Trauma Systems 15

not. Injury care can be either a catastrophic loss have created successful and sustainable trauma
or a significant profit, depending upon the popu- systems, despite economic and political chal-
lation treated and the severity of injury lenges. The single most important factor in
encountered. these regions has been the crystallization of a
As a result, health care today is characterized focused political effort resulting in strong gov-
by intense competition between health-care sys- erning policy, both in the establishment of
tems and health-care providers, driven by eco- authority for operations and in the financing of
nomic forces that create a focus on individual critical system infrastructure. The difficulty in
patient encounters rather than the broad provi- generalizing these successful models lies in the
sion of emergency care to the population as a inherently unique local factors that tipped the
whole. The result is an atmosphere that is highly political scale to the side of decisive action. In
disruptive to the coalition building and coopera- some circumstances, the impetus has arisen
tion necessary in a public health-based trauma from successful grassroots efforts to raise public
system model. The implementation of the ACA interest and awareness, which drive legislative
contains financial incentives for health-care sys- action; while in others, the progress has been
tems to think more broadly in terms of “popula- driven because of a focused interest in the exec-
tion health,” but these incentives may not have a utive branch. In either circumstance, the essen-
beneficial effect on trauma care, as the popula- tial turning point has been in finding the political
tions referred to are actually small diagnosis or will to create policy that provides some objec-
disease-based groups rather than the entire popu- tive authority over the resources necessary for
lation at risk of injury. Moreover, the uncertainty the care of the injured and for that matter all
created by widely variant projections of the true patients with emergency or “unscheduled” ill-
financial impact of the ACA has led to further ness, in order to ensure availability and access,
cost-cutting measures on the part of health-care but without a degree of governmental control
systems and increased economic pressures that that some factions with current society find
work to make trauma system development more unacceptable. The other key element of success-
difficult. ful solutions has been in the ability to find stable
This situation is compounded by the national funding for essential trauma system infrastruc-
trend toward decreased social services and mini- ture, in order to support system oversight,
mization of government intervention that leaves ­quality improvement, and day-to-day ­operations.
most state legislatures and state bureaucracies Efforts that focus solely on supporting trauma
unwilling to take a strong position in establishing centers for underfunded care often result in
standards and regulations governing emergency adverse incentives for overall system
medical care. With no stabilizing authority to development.
intervene, health-care facilities may engage injury The Affordable Care Act (ACA) will certainly
care in areas where it is profitable, while abandon- change the balance of forces and dynamics
ing injury care in others that are less so. The result ­affecting trauma systems. However, it is difficult
is a maldistribution of resources, leading either to to predict in which direction, as some elements
lack of access as described above or to an over- within provisions of the Act stand to increase
supply with duplication of efforts, resources, and funding available for trauma care, while others
increased cost to the region as a whole. remove existing funding streams; and both of
these elements occur in a setting intended to
decrease overall expenditures for health care.
1.5 The Road Ahead Although as yet there has been no grassroots sup-
port or political agenda sufficient to drive a
The challenges to trauma system development policy-­level solution to the nationwide problem
are substantial, but not insurmountable. Several of uniform systems for trauma care, the ACA and
regions, usually of smaller geographic scale, the tools being used in its implementation do
16 R.J. Winchell

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1  The Evolution of Trauma Systems 17

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 The Concept of Damage Control
2
Claudia E. Goettler, Peter V. Giannoudis,
and Michael F. Rotondo

2.1 Historical Management d­ estructive wounds, and there was also delay to
of Injury definitive care. This resulted in the development
of novel operative techniques for trauma, such as
Trauma surgery is just general surgery, but faster pyloric exclusion and distal rectal washout, some
and under blood. – Anonymous
of which have stood the test of time and some of
which have not.
As the majority of trauma resuscitation and
­operation was historically performed by g­ eneral
surgeons, the practice of trauma and surgical
­ 2.2  ailure of a General Surgical
F
critical care developed slowly as a general surgi- Approach in Trauma
cal ­subspecialty by those with special interest in
this patient population. Surgical procedures for The operation was a success but the patient died
anyway. – Anonymous
injury care, therefore, have been based entirely
on ­elective general surgical procedures. Hence,
injury to the stomach would receive an operative Since general surgeons have long been trained to
approach similar to that of a perforated ulcer. identify and repair operatively any diagnosed
This was gradually modified by war experiences. injury or disease, prolonged operative procedures
Patients from the war zone generally had massive for definitive repair were the norm. Patients who
bleed during elective operative procedures either
C.E. Goettler have control maneuvers instituted prior to the vas-
Division of Trauma and Surgical Critical Care, cular incision as in vascular surgery or rapid pres-
Department of Surgery, Brody School of Medicine
sure or clamp control of inadvertent vascular injury
East Carolina University, Greeenville,
North Carolina, USA during a case. Additionally, hemorrhage nearly
always occurs only moments before control is
P.V. Giannoudis
Department of Trauma and Orthopedic Medicine, achieved when the patient is already in an operat-
University of Leeds, Leeds General Infirmary, ing suite, draped, and in many cases already open.
Leeds, UK This is radically different from the physiologic
M.F. Rotondo (*) pattern in trauma patients who are injured min-
Division of Trauma and Acute Care Surgery, utes to hours prior to arriving in the operating
Department of Surgery, University of Rochester
room and hence have been bleeding for an
School of Medicine and Dentistry, Rochester,
New York, USA extended period of time prior to instituting surgi-
e-mail: mfrsurg1@gmail.com cal control. Additionally, this bleeding results in

© Springer International Publishing AG 2017 19

H.-C. Pape et al. (eds.), Damage Control Management in the Polytrauma Patient,
DOI 10.1007/978-3-319-52429-0_2
20 C.E. Goettler et al.

difficulty in obtaining rapid surgical control by 2.3 The Development

obscuring the operative field and tissue planes. of the Abbreviated
Similarly, intestinal contamination, ongoing prior Laparotomy
to operative control, results in an increased
degree of contamination by virtue of both the He who fights and runs away, may live to fight
another day. – JA Aulls, 1876
length of contamination time and the high energy
of intestinal content distribution. Gradually, changes in the operative approach
Finally, elective general surgeons usually have toward this group of extremely ill trauma
time and information, such as imaging and his- patients began to be discussed and published in
tory, to allow planning for operative procedures, the literature. Stone and colleagues were the
even if only during the brief initial workup. In first to describe aborting a laparotomy by the
contrast, surgeons faced with a trauma patient do use of abdominal packing when intraoperative
not know what disease process they will find on coagulopathy developed [1]. This report was
opening, even when guided by a CT scan, result- published in 1983. Several subsequent reports
ing in further delay in control while determining of this technique, specifically for hepatic injury,
injuries. Moreover, these patients are more likely and then a large series showing survival advan-
to be unstable and/or unresponsive, resulting in tage by Burch and colleagues followed [2].
less information and time for operative planning. Unfortunately, adoption of this technique was
Taken in their entirety, these factors – delay in slow and in some cases was deemed a failure to
operative presentation, unknown pathology at the finish operating or an attempt to shift work to
start of operation, difficult and delayed control of another time.
hemorrhage, and contamination – result in a major The next iteration of this technique by
difference between general surgical and trauma Rotondo and colleagues resulted in renaming
patients. This is the concept of physiologic exhaus- this care pattern “Damage Control” [3]. It
tion that is found commonly in traumatized patients should be noted that despite the name, derived
and occasionally in emergency general surgical from the navy ship damage management, this
patients. While elective general surgical patients was a civilian trauma development rather than
should be fully evaluated and optimized before sur- military. The “Damage Control” sequence was
gery, and emergency general surgical patients defined. Since then, and with a new name, the
should be briefly “tuned-up” prior to surgery with technique has become increasingly accepted
fluid boluses, blood, and/or antibiotics, many and has resulted in undoubted decreases in
trauma patients cannot wait even minutes for opera- mortality.
tive intervention due to extreme instability. These
patients do not have any physiologic reserve and
arrive in the OR in extremis. They may not tolerate
the time under anesthesia needed to complete a full 2.4  asic Tenants of Damage
B
operative exploration and repair. Hence, using tradi- Control
tional approaches, these patients died either on the
table during the course of their operation or shortly 2.4.1 D
 amage Control Part 0: Rapid
thereafter, due to ongoing nonmechanical bleeding, Transport to Definitive Care
usually from coagulopathy or from subsequent
multisystem organ failure. The underpinning for A crucial part of salvage in the selected extremely
damage control is that the patient is incapable of unstable trauma patients is the rapid transporta-
undergoing a traditional operative approach due to tion to a center capable of providing definitive
physiological exhaustion and thus needs an abbre- care. The most direct method of transportation
viated initial operation controlling only hemorrhage with the fewest delays in transitional facilities is
and contamination to expedite the aggressive resus- necessary to maximize survival [4]. During this
citation in the intensive care unit. period, judicious resuscitation should be under
2  The Concept of Damage Control 21

way. The traditional approach of normalizing 2.4.3 D

 amage Control Part 2:
vital signs in patients with prolonged transport Resuscitation
times is inadvisable. Permissive hypotension,
resuscitating patients to goal systolic pressure of Once out of the operating room, attention is turned
approximately 90 mmHg with concomitant signs to full resuscitation in the intensive care unit.
of end-organ perfusion, allows for adequate tis- Coagulopathy, anemia, acidosis, electrolyte
sue perfusion while decreasing the potential for abnormalities, and hypothermia should be aggres-
clot disruption from increased hydrostatic sively corrected. Normalization of physiology is
­pressures. For patients who present with injury an indication to return for definitive operative care
complexes generally leading to hemodynamic
­ and is usually accomplished in 24–36 h. With the
instability or those who exhibit instability, this advent and effective use of Damage Control
approach should be extended in the trauma resus- Resuscitation techniques, the frequency and
citation area at the trauma center where Damage degree of physiologic perturbation is decreasing,
Control Resuscitation (blood-plasma-platelets), and the time to normalization is reduced.
limiting crystalloids and utilizing goal-directed However, patients who fail to improve or have
hemostatic resuscitation, is preferred. Damage subsequent worsening of parameters must be
Control Resuscitation, the details of which are considered as having either ongoing bleeding or a
covered in subsequent chapters of this text, com- missed injury. These patients are returned to the
pliments the Damage Control Surgery Concept, operating room as an emergency for another
and when utilized together, mortality can be sig- look, which should be thought of as a return to
nificantly reduced. Damage Control Part 1, with limited goals of
hemorrhage control, identification of injury, and
prevention of ongoing contamination. In some
2.4.2 D
 amage Control Part 1: Rapid patients, several cycles through Damage Control
Control of Hemorrhage Parts 1 and 2 may be necessary.
and Contamination

Operative intervention is focused on full expo- 2.4.4 D

 amage Control Part 3:
sure and rapid hemorrhage control. For major Return for Completion
hepatic injury, packing is optimal, though multi- of Operative Repairs
ple other more time-consuming methods may be
necessary. Major vascular injury that cannot be When fully resuscitated and physiologically nor-
safely treated by ligation can be considered for malized, patients will tolerate a second surgical
vascular shunting. However, ongoing arterial insult and longer operative times. They are then
bleeding, whether in a viscera or cavity, will not returned to the operating room for unpacking, sec-
be controlled by packing alone – surgical control ond look, and definitive ­management of injuries.
is required. Intestinal contamination should be During this operation, all injuries should be clearly
controlled by whipstitch, intestinal ligation, or identified and repaired, including recreation of
stapling. No attempts at formal resection are intestinal c­ ontinuity. The luxury of the second look
undertaken, and the intestine is left discontinu- as well as potential difficulties with abdominal wall
ous. Details of management of specific organs closure has led to an increase in primary a­ nastomosis
are found in further chapters. The abdomen is for colonic injuries, with good results. Feeding
closed by one of many quick temporary methods. access should be considered in all of these patients.
The entire operative intervention should take About half of this selected p­ opulation will be able to
about 1 h and certainly no longer than 90 min. tolerate primary f­ascial closure during this opera-
Effective utilization of Damage Control tion. The remainder is managed with sequential clo-
Resuscitation may indeed extend this window of sure methods, primary allograft closure, or
operative intervention. ­granulation and skin grafting (Figs. 2.1 and 2.2).
22 C.E. Goettler et al.

Fig. 2.1  As edema resolves, the defect becomes smaller Fig. 2.3  Once the skin graft can be separated from the
and may be able to be closed primarily. The vacuum underlying intestines, the patient can undergo component
dressing is easily and inexpensively created with plastic separation and reconstruction of the abdominal wall
sheeting against the bowels, gauze, drains, and an adhe-
sive dressing

hemostatic techniques – visceral edema is more

limited and definitive closure rates are now
steadily climbing [5].
The remaining patients are treated with a tem-
porizing method, such as vicryl mesh and skin
grafting, until they have completely recovered
from their metabolic insult. Typically, these
patients will be at home for 6–9 months, recover-
ing mobility and optimal nutritional condition
during which time the skin graft separates from
the underlying intestines. At this time, an elective
return to the operating room is undertaken for
abdominal closure, with component separation
Fig. 2.2  Abdominal defects that cannot be closed pri-
and/or mesh or allograft, as well as stoma rever-
marily are allowed to granulate, usually via absorbable sal if needed (Fig. 2.3). Long-term outcomes in
mesh, and then are skin grafted these patients have been shown to be quite good.

2.4.5 D
 amage Control Part 4: 2.5 I ndications for Damage
Definitive Abdominal Closure Control

A section of patients managed with Damage 2.5.1 Early Decision Making

Control cannot be safely closed at the completion
of Damage Control Part 3, either due to high In order for patients to benefit from a Damage
intra-abdominal pressures or contamination Control sequence, the decision to abort operative
requiring repeated washouts. Some can be closed intervention must be made early. It should be con-
subsequently during their hospital course. sidered even prior to the arrival of the patient if
Historically 50–60 % of Damage Control patients there is hypotension in transport or in the trauma
were discharged with definitive abdominal clo- resuscitation area. While hypotension may well
sure but with the application of Damage Control resolve with resuscitation, it is an early indicator
Resuscitation and concomitant goal-directed that the patient is not prepared to ­tolerate a pro-
2  The Concept of Damage Control 23

longed operation. Elevated lactate and base deficit multiple widely spaced intestinal injuries or com-
are also early warning signs of physiologic bined vascular and intestinal injuries. Other
derangement. While neither alone is an indicator sources of blood loss also contribute, though they
for abbreviated laparotomy, they should induce are of lesser immediate concern, such as extrem-
the thought process. Absolute indicators will be ity fractures and lacerations; but they cause con-
discussed below; however, it cannot be stressed cern as the loss of blood from these is often
enough that a Damage Control operation should underestimated when hidden either by the skin or
take only 60–90 min, and hence the decision to the drapes. Similarly orthopedic injuries can and
abort should be made early in the operation. should be temporized in these patients [9].
Waiting to abort until the patient has reached Multi-compartment injuries also call for
physiologic exhaustion makes salvage extremely Damage Control, such as management of hemor-
unlikely and results in almost certain death. rhage of the abdomen and the chest. Clearly, full
management of abdominal injuries and closure
would compromise a patient who also requires
2.5.2 Triad of Death thoracic exploration. Hence, rapid termination
and temporization within one compartment fol-
There is extensive evidence that coagulopathy, lowed rapid control and temporization within
acidosis, and hypothermia all interact to worsen another compartment cuts the total operative
each other in a vicious spiral that eventually time, blood loss, and heat and evaporative losses.
results in ongoing hemorrhage and death. Early This will rarely result in patients with Damage
recognition of any of these findings is an indica- Control dressings on both abdominal and tho-
tor for Damage Control Resuscitation as well as a racic incisions or on combined abdominal and
Damage Control abbreviated laparotomy. While sternotomy incisions (Fig. 2.4).
many studies indicate varying absolute numbers, Any other potentially life-threatening extra-­
temperature less than 34, pH less than 7.2 (or abdominal injury that requires timely interven-
base excess greater than 8 in a patient with a cor- tion is an indicator to stop operating after
rected pH due to hyperventilation), and/or labo- hemorrhage and contamination control and pro-
ratory or clinical evidence of coagulopathy vide a temporary closure. This allows for more
should result in initiation of the Damage Control rapid evaluation of these associated injuries such
Approach [6]. Continued interaction with the as severe intracranial injury or aortic transection,
anesthesia team is necessary to maintain aware- as well as early and aggressive correction of
ness of these factors while operating. There is coagulopathy, which could contribute to mortal-
growing evidence of improved outcomes with ity in these injuries. This is also the most efficient
layering damage resuscitation into damage con- way to get patients with liver or pelvic injuries to
trol laparotomy. Clearly as our understanding of angiogram if indicated.
resuscitation has evolved over the last 15 years
and refinement of Damage Control Surgery has
ensued, survival rates continue to improve [7, 8].

2.5.3 Associated Injuries

Other injuries may contribute to the decision to

interrupt laparotomy. Patients with multiple
intra-abdominal injuries should be considered for
abbreviated laparotomy at each stage of repair, as
the time necessary for complete repair becomes Fig. 2.4  Damage control of combined sternotomy and
rapidly prohibitive. This is seen in patients with laparotomy. Note massive abdominal distention
24 C.E. Goettler et al.

Lastly, the variability of the physiologic now orthopedic injuries are treated by Damage
reserve should be assessed for the patient. Older Control techniques, which is the focus of this
patients and/or those with comorbidities are text. The utilization of this technique can be
likely to be intolerant of long operative times and expected to improve the limb salvage, though
should have frequent reassessment of the need data from large studies are not yet available.
for abortion of the procedure. Additionally, the concept of damage control and
the lethal triad has also spilled over into general
surgery and is likely resulting in improved out-
2.5.4 P
 redicted or Present comes in this population as well.
Abdominal Compartment
Syndrome
2.7 Summary and Conclusion
While abdominal compartment syndrome was a
pervasive problem 20 years ago, it is encountered The evolution of the abbreviated laparotomy or
far less frequently now with the use of Damage “Damage Control” for trauma has improved patient
Control Resuscitation. Nonetheless, prediction of survival by decreasing the operative stress on
patients who are likely to develop abdominal patients in physiologic exhaustion. This technique
compartment syndrome, and therefore selectively requires rapid control of bleeding and contamina-
leaving these patients open with a temporary tion, temporary abdominal closure, and then inten-
abdominal closure rather than closing fascia still sive care resuscitation of physiology with return to
remains an important adjunct to Damage Control the operating room for eventual definitive opera-
Surgery. This is done even in patients with defini- tive repair. This sequence should be utilized in
tive completion of their operation to prevent the patients with coagulopathy, acidosis, and hypother-
cascade of physiologic injury occurring with mia. While mortality in a subset of critically ill
abdominal compartment syndrome. Patients at trauma patients has decreased with this modality,
risk for developing massive visceral edema are these patients have a very high incidence of mor-
those who have received more than 10–15 units of bidity and frequently require prolonged hospital-
blood products and/or more than 5 L of crystalloid ization and multiple operative procedures. The
[10]. Additionally, any patient with increasing addition of Damage Control Resuscitation has not
peak ventilatory pressures of more than 10 points only decreased mortality further but also reduced
at fascial approximation is at extremely high risk. morbidity. The success of Damage Control in man-
agement of abdominal pathology has led to the
expansion of the concept into orthopedic and vas-
2.5.5 Planned Reoperation cular trauma and into all aspects of surgical care.

Finally, temporary abdominal closure can be done

in any patient who requires further evaluation prior References
to completion of repair of injuries, such as planned
second look or serial washouts or debridement. 1. Stone HH, Strom PR, Mullins RJ. Management of the
major coagulopathy with onset during laparotomy.
Ann Surg. 1983;197:532–5.
2. Burch JM, Ortiz VB, Richardson RJ, Martin RR,
2.6  xpansion of Damage
E Mattox KL, Jordan GL. Abbreviated laparotomy and
Control Principles planned reoperation for critically injured patients. Ann
Surg. 1992;215:476–84.
3. Rotondo MF, Schwab CW, McGonigal MD, Phillips
With the success of the Damage Control sequence III GR, Fruchterman TM, Kauder DR, Latenser BA,
in visceral trauma and its general adoption by the Angood PA. “Damage control”: an approach for
trauma community, it is increasingly utilized in improved survival in exsanguinating penetrating
abdominal injury. J Trauma. 1993;3:375–82.
other traumatic injuries [11, 12]. Vascular and
2  The Concept of Damage Control 25

4. Sagraves SG, Rotondo MF, Toschlog EA, Schenarts the evolution of damage control resuscitation: analysis
PJ, Bard MR, Goettler CE. Brief interval transfer of 1,030 consecutive trauma laparotomies. Published
(BIT): the morbid consequence of delay to the trauma ahead of print October 2016 http://journals.lww.com/
center in a rural patient demographic (abstract). jtrauma/Abstract/publishahead/Improving_mortality_
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5. Loftus T, Jordan JR, Croft CA, Smith RS, Efron PA, 9. Cué JI, Cryer HG, Miller FB, Richardson JD, Polk Jr
Mohr AM, Moore FA, Brakenridge SC. Temporary HC. Packing and planned reexploration for hepatic
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sepsis: different patients, different outcomes Published of a useful technique. J Trauma. 1990;30:1007–13.
ahead of print October 2016. http://journals.lww.com/ 10. Pape HC, Giannoudis P, Krettek C. The timing of
jtrauma/Abstract/publishahead/Temporary_abdomi- fracture treatment in polytrauma patients: relevance
nal_closure_for_trauma_and.99337.aspx. of damage control orthopedic surgery. Am J Surg.
6. Morris JA, Eddy VA, Blirman TA, Rutheford EJ, Sharp 2002;183:622–9.
EW. The staged celiotomy for trauma: issues in unpack- 11. Reilly PM, Rotondo MF, Carpenter JP, Sherr SA,
ing and reconstruction. Ann Surg. 1993;217:576–86. Schwab CW. Temporary vascular continuity during
7. Duchesne JC, Kimonis K, Marr AB, et al. Damage damage control: intraluminal shunting of proximal
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trol laparotomy: a survival advantage. J Trauma. 1995;39(4):757–60.
2010;69:46–52. 12. Rasmussen TE, Clouse WD, Jenkins DH, et al. The
8. Joseph B, Azim, A, Zangbar B, Bauman ZM, O’Keeffe use of temporary vascular shunts as a damage control
T, Ibraheem K, Kulvatunyou N, Tang A Latifi, R, Rhee adjunct in the management of wartime vascular injury.
P Improving mortality in trauma l­aparotomy through J Trauma. 2006;61:8–12.
 Changing Epidemiology
of Polytrauma
3
Fiona Lecky, Omar Bouamra,
and Maralyn Woodford

Epidemiology is the study of health and d­isease only just started to distinguish between polytrauma
in populations, the scientific approach typifying and major injury to a single body system. However,
public health medicine. The paradigms are some- it still sets an important context for more detailed
what different to the reductionist approach of much descriptions of polytrauma found in trauma regis-
clinical science, which seeks to understand disease tries. This chapter will first update on the global
processes at an “omic” level. The rationale that injury burden prior to a polytrauma focus.
underpins ­epidemiology suggests effective disease
­control must begin and end by understanding the
impact of a disease (and its prevention/management 3.1 Global Burden of Injury
strategies) at a population level, globally, nationally
and locally, including the identification of vulner- Trauma fulfils the disease classification criteria for
able groups, aetiological factors and societal costs. a global pandemic, this being a recurrent and sig-
An epidemiological perspective on polytrauma – nificant cause of morbidity and mortality over time
significant injuries affecting more than one body and across continents despite efforts to control its
region – and its management must draw from the impact. Worldwide over 10,000 people die every
significant “injury control” literature. The latter has day as a result of an injury [1]. Injury accounts for
10% of all disability-adjusted years of life globally
lost. The injury control literature identifies road
F. Lecky (*)
Centre for Urgent and Emergency Care, Health traffic collisions (RTC), falls and intentional vio-
Services Research, School of Health and Related lence (including self-harm) as the major vectors of
Research, University of Sheffield, Sheffield S14DA, traumatic injury, and this has been the case since
United Kingdom 1990 [2]. Undoubtedly the major burden of injury
Trauma Audit and Research Network, Institute of is increasingly occurring in middle- and low-
Population Health, Health Services Research and income countries as they industrialise and adopt
Primary Care, University of Manchester, 3rd Floor
Mayo Building, Salford Royal Hospital, motorised transportation. Despite a lower popula-
Salford M68HS, United Kingdom tion incidence, injury remains the commonest
e-mail: f.e.lecky@sheffield.ac.uk cause of death and disability in children and young
O. Bouamra • M. Woodford adults in the developed world [2].
Trauma Audit and Research Network, Institute of Annual incidence and trends over time vary
Population Health, Health Services Research and across the developed world. Data is obtained
Primary Care, University of Manchester, 3rd Floor
Mayo Building, Salford Royal Hospital, from national statistics which use International
Salford M68HS, United Kingdom Classification of Disease codes, a taxonomy

© Springer International Publishing AG 2017 27

H.-C. Pape et al. (eds.), Damage Control Management in the Polytrauma Patient,
DOI 10.1007/978-3-319-52429-0_3
28 F. Lecky et al.

with limited descriptions of injury severity. The An abbreviated injury score of greater than 2
Abbreviated Injury Scale (AIS) dictionary has a points in at least two body regions in conjunction
greater level of detail (over 2000 injury codes) and with a pathological value of another kind. Five dif-
allocates to every injury a severity score between ferent parameters were identified as follows: sys-
1 (mild) and 6 (maximal) [3]. These can be sum- tolic blood pressure smaller or equal 90 mmHg,
mated into the Injury Severity Score (ISS) [4] as a Glasgow Coma scale equal or smaller than 8
global reflection of the anatomical s­ everity of injury points, base excess smaller or equal 6.0, partial
suffered by each individual patient. Severe injury is thromboplastin time greater or equal 40 seconds
defined as ISS >15. Within Europe, most hospital and age greater or equal 70 years [5]. We have
admissions with injury have much lower ISS values previously identified that national trauma regis-
(range 4–8), being due to single isolated limb frac- tries are best placed in this regard and utilised the
tures in children or the elderly (falls) and isolated Trauma Audit and Research Network (TARN), the
mild head injury (blunt assault) in young adults. largest European trauma registry to this end [6, 7].
It is important to note that with the Box 3.1
definition, the limbs and bony pelvis constitute
3.2 Defining Polytrauma one body region; therefore multiple limb frac-
and Data Sources for Study tures or a limb and pelvic fracture will not consti-
tute polytrauma without injuries to either head/
As precise descriptions of injury severity are abdomen/thorax/face/external areas.
required to diagnose polytrauma (Box 3.1),
­databases using AIS as opposed to ICD injury
classifications are needed. The definition of poly- 3.3 Changing Epidemiology
trauma has been renewed recently in an interna- of Polytrauma
tional panel and the following parameters were
calculated on the basis of a nationwide registry: In 2007 we characterised polytrauma epidemiol-
ogy over the period 1989–2003; we have repeated
this analysis utilising a 2008–2013 data set which
enables us to study the changing epidemiology of
Box 3.1
polytrauma [6, 7].
Polytrauma can be defined as significant In this recent study of over 180,000 patients
injurya in at least two out of the following submitted to TARN, it can be seen from Table 3.1
six body regions: that most patients eligible for TARN have not
Head, neck and cervical spine
experienced polytrauma.
Face For there to be significant trauma to more than
Chest and thoracic spine one body regions, the ISS should be >18, and the
Abdomen and lumbar spine median ISS for all age groupings is 9 in the
Limbs and bony pelvis trauma registry sample. The mortality rates
External (skin) increase significantly after age 65 when RTC
causes a much lower proportion of injuries.
a
Significant injury = abbreviated injury score of ≥3 Within this age group, there is also a reversal of
out of 6 male preponderance and an association of higher
mortality with male gender which is probably

Table 3.1.  Trauma Audit and Research Network data

Age groups 0–15 n = 12,647 16–65 n = 110,646 >65 n = 60,548
Age (years) (median) 7.30 44.30 81.30
ISS 9 9 9
% male 68.6% 70.7% 42.3%
% injured by RTC 30.2% 32.0% 9.5%
Mortality % 2.4% 3.7% 10.8%
3  Changing Epidemiology of Polytrauma 29

due to comorbidity and has been described to 41 years in younger adults and 75–79 years in
­elsewhere [8]. The major changes from our previ- older adults, whereas in children it has fallen
ous epidemiological characterisation are: from 11 to 7 years [6].

(i) The increase in the proportion of all major

trauma sustained by older adults from 3.4 Polytrauma Demography,
21% in 1989–2003 to 33% in this series Causes, Incidence
(p < 0.001), reflecting perhaps the ageing Within Trauma Registry
of the population and also a cohort of frail and Outcome
­people – vulnerable to falls – who now sur-
vive to beyond 65. The latter may be due It can be seen from Table 3.2 that 12%
to improved lifestyles, better primary care (22,032/183,841) of trauma registry cases have
detection/management of risk factors for polytrauma, that is, significant injuries in more
early deaths and better secondary care. than one body region (given that the limbs and
(ii) The reduction in the proportion of all major pelvis constitute one body region). This is a slight
trauma that is caused by RTCs in children increase from our previous report of 10% preva-
(from 46% to 30%), adults (from 40% to lence and is accounted for by a relative increase
32%) and most notably in older people of 30% (11.5–15.0) in the proportion of all major
(from 19% to 9%) which is consistent with trauma cases in younger adults resulting in poly-
the hypothesis expressed in (i). Other mech- trauma. This finding may seem a little counterin-
anisms such as falls in older people and tuitive with a fall in proportion of all major
sport in the young now predominate. trauma being caused by RTCs and may reflect
(iii) Within each age/gender cohort, a halving of better detection of polytrauma with the increased
mortality in acute care despite no change in use of 3D imaging. Similar to our previous analy-
the median ISS (mortality rates were 5.5, 7.9 sis, the risk of polytrauma is lowest in older
and 24.7% for male children, younger adult adults (7.1%). The median ages for polytrauma
males and older adult males in 1989–2003, do now (in contrast to our previous report) differ
respectively). This may reflect improved significantly from that from other trauma registry
care or increasing health in the population, cases for children (10.2 versus 7 years) and
hence improved resilience to major injury. younger adults (36.5 versus 45 years), less so for
older adults (78.1 versus 81 years).
The gender split within each age cohort is The proportion of polytrauma cases caused by
unchanged from 1989 to 2003, but the median road traffic collisions (RTC) approximately dou-
age for all TARN patients has increased from 33 bles when compared to proportion of all major

Table 3.2.  Trauma Audit and Research Network

Polytrauma cases by age groups, 2008–2013
Age groups 0–15 16–65 >65 Total
Polytrauma 1198 16,547 4287 22,032
Proportion of all 9.5% 15.0% 7.1% 12.0%
trauma cases %
Age (years) (median) 10.20 36.50 78.10 41.90
ISS (median) 29 29 26 29
Cause of injuries RTC 841 10,410 1561 12,812
% 70.2% 62.9% 36.4% 58.2%
Gender Male 789 12,811 2297 15,897
% 65.9% 77.4% 53.6% 72.2%
Female 409 3736 1990 6135
% 34.1% 22.6% 46.4% 27.8%
Mortality at 30 days % n 120 1685 1050 2855
% 10.0% 10.2% 24.5% 13.0%
30 F. Lecky et al.

injuries caused by RTCs. The RTC proportion racic injury, but in c­ontrast to thoracic injury,
quadruples in older adults (36 versus 9%). significant TBI injury occurs in isolation in three
However, the proportion of polytrauma cases quarters of cases. Significant thoracic trauma is
caused by RTCs across all age groups has fallen more likely to occur in the context of polytrauma
to 58% overall – from 73% in 1989–2003. This (15,288/33,705 = 45%) as is significant abdomi-
fall in has occurred most dramatically in older nal trauma (3741/6880 = 54%). Significant
adults where polytrauma is now caused by RTCs abdominal trauma however is present in only
in only 36% of cases compared to 69% in 1989– 17% of polytrauma cases (3741/22,032). Injuries
2003, whereas the proportion has only reduced to the face and external (skin) body regions are
by 10% in absolute terms in the other age groups rare in the context of polytrauma. The increas-
[6]. Penetrating trauma is responsible for 3.9% ing prevalence of thoracic trauma and reduction
(n = 848) of all polytrauma cases over this time- in prevalence of extremity injury is the main
frame, an increase on previous of 2.1%. Male observed change in polytrauma injury pattern
preponderance decreases somewhat in children when compared to previous study.
(66% vs. 68%, a change in direction from 1989 to
2003) and increases in younger and older adults
by 7% and 10%, respectively. 3.6  olytrauma Mortality, Impact
P
The ISS scores of polytrauma patients are tre- of Age and Body Area
ble that of patients with major isolated injury (29 and Changes over Time
vs 9) but are slightly higher than the median of 25
previously reported; despite this, mortality asso- Table 3.3 indicates that polytrauma with TBI
ciated with polytrauma has halved in nearly all has generally the highest mortality rate across
age gender cohorts from 20% to 10% in those all three age groups (12.5%, 16%, 29.9%). In
<65 and from 40% to 20% in those >65 years). children, polytrauma with thoracic trauma con-
However, mortality still increases 2.5–4-fold fers the highest risk of mortality (12.6%),
across the age groups when compared to isolated whereas in older adults it is polytrauma with
injury to approximately 10% in the young and abdominal injury (31%). This is somewhat
24% in those over 65 years. In this cohort, 62% changed from our previous analysis where
(versus 75% in 1989–2003) of polytrauma deaths abdominal polytrauma was the most lethal
occur in children and people of working age [6]. across all age groups. For isolated injuries and
polytrauma, mortality does not appear signifi-
cantly different between children and adults of
3.5  atterns of Injury as Markers
P working age, but there is a sharp rise in mortal-
for Polytrauma and Changes ity for all patterns of injury after 65 years; this
over Time was true in our earlier study. Interestingly the
relative increase in mortality with age being
Of the 22,032 polytrauma cases detailed here, greater for cases of isolated injury in our previ-
50% (11,122/22,032) have at least one limb+/ ous analysis still applies.
or pelvic fracture – this is a marked reduction In terms of overall mortality burden, it is first
from our previous polytrauma series where interesting to note that the impact of polytrauma
the 73% of cases had these extremity injuries. is greater than the sum of its parts for children
As per our previous analysis, however, most and young adults. For example, if the rates of
(47,581/58,703) = 81%) extremity injuries occur mortality for isolated injuries of the limb/pelvis,
in isolation. Half of all polytrauma cases have a brain, thorax and abdomen are summated for
traumatic brain injury (TBI) and two thirds (as children from Table 3.3, this comes to 6.1%
opposed to 50% in our previous report) a tho- which is less than the polytrauma mortality rates
3  Changing Epidemiology of Polytrauma 31

Table 3.3  Patterns of injury and mortality in polytrauma and isolated injury, by age group
Injury type for polytrauma
Frequency Percent
Blunt 21,183 96.1
Penetrating 849 3.9
Total 22,032 100.0
Patterns of injuries and mortality in polytrauma and isolated injury, by age groups, 2008–2013
0–15 years 16–65 years >65 years Overall
mortality %, mortality %, mortality %, mortality %,
No. of deaths No. of deaths No. of deaths No. of deaths
Limb AIS 3+ Isolated (n) 47,581 0.1% (4) 0.8% (232) 5.2% (721) 2% (957)
Polytrauma (n) 11,122 6.5% (36) 7.5% (639) 19.6% (401) 9.7% (1076)
TBI AIS 3+ Isolated (n) 39,745 2.3% (75) 6.6% (1388) 19.3% (2973) 11.2% (4436)
Polytrauma (n) 11,302 12.5% (103) 16% (1298) 29.9% (713) 18.7% (2114)
Thoracic Isolated (n) 18,417 2.7% (11) 2.2% (266) 9.7% (583) 4.7% (860)
AIS 3+ Polytrauma (n) 15,288 12.6% (102) 12.4% (1474) 28.4% (738) 15.1% (2314)
Abdominal Isolated (n) 3139 1% (6) 2.3% (52) 7.6% (18) 2.4% (76)
AIS 3+ Polytrauma (n) 3741 11.2% (26) 14.9% (463) 31.9% (127) 16.5% (616)

for ­children with TBI/chest or abdominal inju- trauma registry, true polytrauma (ISS>17 with
ries. Although polytrauma accounted for only at least two AIS 3+ injuries) using abbreviated
12% of cases in this trauma registry sample, it injury scale criteria occurs, in only 12%
accounted for almost a third (2860/9189 = 31%) (2008–2013) of cases but causes up to one
of all deaths, the remainder occurring mainly in third of all deaths in patients reaching hospital
the context of isolated significant head injury and alive, mainly in adults <65 years. Road traffic
limb fractures in the elderly. This analysis has not collisions remain the predominant cause, but
dealt in detail with the disability consequences of falls are catching up. The thorax and head are
polytrauma; inevitably they are considerable, but now the most frequently injured body area in
large series are rare due to the challenges of fol- polytrauma as opposed to limb/pelvic injury in
low-­up [9]. It appears that a major improvement previous reports. However, thoracic and
in care for polytrauma groups of all ages has abdominal traumas remain specific markers for
occurred as evidenced in the large relative the presence of polytrauma. Traumatic brain
decreases in in mortality for all age groups injury in the context of polytrauma carries the
regardless of body region injured compared to greatest ­mortality risk. Polytrauma is less fre-
1989–2003. The biggest gains have been in the quent in those over 65 years, but the increasing
management of polytrauma in children (Fig. 3.1). silver trauma phenomenon with the associated
This now means that polytrauma accounts for a higher ­ mortality means this generation
third rather than a half of all in hospital trauma accounts for one third of recent polytrauma
deaths. deaths. Major improvements in mortality (50%
in relative terms) are observed since this regis-
try reported on a 1989–2003 cohort. However,
3.7 Summary within the younger age groups, the mortality
associated with polytrauma is greater than the
Injury is a global pandemic and the second sum of its parts suggesting a role for further
most costly disease worldwide with the burden targeted improvements in care across the
­
set to increase. Within the largest European generations.
32 F. Lecky et al.

80.0%
Percentage decrease in mortality by body region and age

73.8%
70.0%

65.6%
61.8%
60.0%
58.0%
56.6%

50.0% 52.0% 51.6% 51.5%

49.2%
49.3% 0 – 15
51.2%
47.0% 16 – 65
40.0%
>65

30.0%

20.0%

10.0%

0.0%
Head Thorax Abdomen Limbs

æ Mortality rate 2008 - 2013 ö

Fig. 3.1  Relative % decrease in polytrauma mortality by body region and age ç ÷ ´ 100%
è Mortality rate1989 - 2003 ø

consensus process and proposal of the new Berlin

References Definition. J Trauma and Acute Care Surgery. 2014;
77:780–86.
1. Krug EG, Sharma GK, Lozano R. The global burden 6. Lecky FE, Bouamra O, Woodford M, Alexandrescu R,
of injuries. Am J Public Health. 2000;90:523–6. O'Brien S. Epidemiology of polytrauma. In: Pape
2. Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K, H-C, Peitzman A, Schwab W, Giannoudis P, editors.
Aboyans V, et al. Global and regional mortality from Damage control management in the polytrauma
235 causes of death for 20 age groups in 1990 and 2010: patient. New York: Springer; 2010. p. 13–24.
a systematic analysis for the Global Burden of Disease doi:10.1007/978-0-387-89508-6_2.
Study 2010. Lancet. 2012;380(9859):2095–128. 7. TARN. www.tarn.ac.uk.
3. Committee on Injury Scaling, Association for the 8. Bouamra O, Wrotchford AS, Hollis S, Vail A,
Advancement of Automotive Medicine. The abbrevi- Woodford M, Lecky FE. A new approach to outcome
ated injury scale. 2005 Revision. Update 2008. Des prediction in trauma: a comparison with the TRISS
Plaines: 2008. model. J Trauma. 2006;61:701–10.
4. Baker SP, O’Neill B, Haddon W, Long WB. The injury 9. Pape H-C, Zelle B, Lohse R, Hildebrand F, Krettek C,
severity score: a method for describing patients with Panzica M, Duhme V, Sittaro NA. Evaluation and out-
multiple injuries and evaluating emergency care. come of patients after polytrauma – can patients be
J Trauma. 1974;14:187–96. recruited for long-term follow up? Injury. 2006;37(12):
5. Pape HC, Lefering R, Butcher N, et al. The 1197–203.
­definition of polytrauma reisited: An international
 Response to Major Injury
4
Todd W. Costantini and Raul Coimbra

4.1 Systemic Inflammatory Table 4.1  Systemic inflammatory response syndrome

Response Syndrome (SIRS) criteria
Two or more of the following:
The systemic inflammatory response syndrome  Temperature >38 °C or <36 °C
(SIRS) after injury occurs as a result of a com-  Respiratory rate >20 breaths per minute or pCO2
plex set of interactions which result in a sub- <32 mmHg
stantial host immune cell response and  Heart rate >90 beats per minute
activation of both the complement and coagula-  White blood cell count >12,000 or <4000 or >10%
bands
tion cascades. SIRS is defined as two or more
of the following: (1) temperature >38 °C or
<36 °C, (2) respiratory rate >20 breaths per
minute or pCO2 <32 mmHg, (3) heart rate >90 4.2 Immune Response to Injury
beats per minute, and (4) white blood cell count
>12,000 or <4000 or >10% bands (Table 4.1). While the SIRS response in sepsis is mediated
This SIRS response occurs within minutes of by invading pathogens, major trauma incites a
injury as a result of tissue hypoperfusion and sterile inflammatory response (Fig. 4.1). In
tissue injury. While an adequate host inflamma- trauma patients, hemorrhage can result in a
tory response is an essential component of the period of ischemia that results in tissue hypoxia.
injury response, there is also the potential to The restoration of adequate volume and tissue
cause significant damage to host tissues. A sus- perfusion after control of hemorrhage and resus-
tained inflammatory response to injury has citation improves blood flow and causes reperfu-
been correlated with increased morbidity and sion injury to injured cells. This
mortality in trauma patients [1]. ischemia-reperfusion injury causes oxidative
stress on the injured cells and results in the
release of free radicals and pro-­ inflammatory
cytokines. If tissue ischemia is prolonged or
T.W. Costantini, MD, FACS ischemia-reperfusion injury severe enough, cells
R. Coimbra, MD, PhD, FACS (*) may undergo apoptosis or necrosis and further
Division of Trauma, Surgical Critical Care, Burns drive inflammation. Major trauma also elicits an
and Acute Care Surgery, Department of Surgery,
UC San Diego Health, 200 W. Arbor Drive #8896,
immune response caused by tissue injury related
San Diego, CA 92103, USA to tissue damage itself. Both ischemia-­
e-mail: rcoimbra@ucsd.edu reperfusion injury and tissue damage cause an

© Springer International Publishing AG 2017 33

H.-C. Pape et al. (eds.), Damage Control Management in the Polytrauma Patient,
DOI 10.1007/978-3-319-52429-0_4
34 T.W. Costantini and R. Coimbra

Ischemia-reperfusion injury or tissue damage

Release of damage associated molecular patterns (DAMPs)

Innate immune cell

Coagulation cascade Complement pathway
activation

Pro-inflammatory Endothelial cell

Vascular permeability
cytokine release activation

Systemic inflammatory response and host tissue injury

Fig. 4.1  Severe injury causes a systemic inflammatory molecular patterns (DAMPs). This injury results in acti-
response. Tissue ischemia-reperfusion after hemorrhage vation of the innate immune system, coagulation pathway,
or tissue damage from trauma can elicit a sterile inflam- and complement cascade leading to a systemic inflamma-
matory response caused by release of damage-associated tory response (SIRS) and host tissue injury

innate immune response. The innate immune inflammatory response. Binding of a DAMP to
system consists of peripheral blood mononuclear the TLR activates numerous intracellular sig-
cells (PBMC) and polymorphonuclear leuko- naling pathways which upregulate the produc-
cytes (PMN). Major injury results in the release tion of pro-inflammatory transcriptional
of damage-associated molecular patterns factors. These transcriptional factors, includ-
(DAMPs) which are released by damaged or ing nuclear factor-­kappa B (NF-ΚB), activator
dying host tissues and secreted by activated protein-1 (AP-1), and phosphoinositide
immune cells. The innate immune system initi- 3-kinase (PI3K)/Akt, propagate the inflamma-
ates an inflammatory response when these tory response through the production of cyto-
DAMPs, also known as alarmins, bind to pattern kines and acute-phase proteins.
recognition receptors on host inflammatory cells Pro-inflammatory cytokines such as tumor
or activate the complement cascade. DAMPs are necrosis factor-alpha (TNF-α) and interleukin
either proteins released from injured cells or (IL)-1β exert several downstream effects which
products of abnormal cellular metabolism. further propagate the inflammatory response.
Common protein DAMPs include heat shock TNF-α modulates the immune response by
proteins and high-mobility group box 1 protein stimulating the production of other pro-­
(HMGB-1), while DNA, mitochondrial DNA, inflammatory mediators such as leukotrienes
and microRNA are common nonprotein DAMPs and prostaglandins which together mediate the
released from injured cells [2]. DAMPs released inflammatory response after injury by increas-
after injury bind to pattern recognition receptors ing capillary leak, causing damage to epithelial
including toll-like receptors (TLRs) and nod- and endothelial barriers, and increasing adhe-
like receptors that propagate the injury response sion molecules on both inflammatory cells and
through activation of immune cells. vascular endothelial cells.
The TLR family is present on endothelial Recent studies from the Inflammation and
and immune cells and is a key mediator of the the Host Response to Injury program (“Glue
4  Response to Major Injury 35

Increased gene expression

Innate immune response

Time post-injury
Decreased gene expression

Adaptive immune response

Fig. 4.2  Severe injury alters leukocyte gene expression. suppression of adaptive immunity genes [1]. This sug-
Injury causes wide-ranging changes in leukocyte gene gests a systemic inflammatory response from innate
expression after blunt trauma. Leukocyte gene analysis immune cells with a simultaneous compensatory anti-­
has demonstrated increased expression of genes associ- inflammatory response (CARS) from adaptive immune
ated with the innate immune response with a simultaneous cells (Modified from Xiao et al. [1])

Grant”) have given important insights into the Table 4.2  Components of the innate immune system
immune response to injury [3]. Prior dogma Immune cells Function
proposed a model describing the inflammatory  Neutrophils Most abundant phagocytic cell,
response as an initial period of SIRS followed produce reactive oxygen species
by a compensatory anti-inflammatory response that can damage host tissues
 Monocytes Recruited to sites of tissue injury,
(CARS) that was associated with immunosup-
mature into macrophages
pression [4]. Analysis of the leukocyte genomic  Macrophages Phagocytosis of cellular debris
response from severe blunt trauma patients and necrotic cells
enrolled in the Glue Grant demonstrated  Natural killer Secrete cytokines, recruit other
increased expression of genes associated with cells innate immune cells
systemic inflammation and innate immune  Dendritic cells Antigen presentation, activate T
response with a simultaneous suppression of cells of adaptive immune system
Physical barriers Function
adaptive immunity genes consistent with the
 Skin Physical barrier to external
CARS. They found that over 80% of cellular environment
functions and signaling pathways after severe  Mucosal Physical, chemical, and
blunt trauma were altered, a finding the authors epithelial cells mechanical barrier to prevent
termed a “genomic storm” [1]. While there was pathogens from accessing
no difference in the genomic changes in patients underlying tissue and immune
cells
that suffered a complicated recovery from
injury, the genomic changes were increased and
lasted longer than patients with an uncompli- 4.3 Innate Immune Cells
cated recovery. These findings have led to a new
model describing the immune response to injury The innate immune system gives nonspecific
that describes a simultaneous dysregulation of immunity that provides the first line of defense
both the innate and adaptive immune responses against injury and infection (Table 4.2). These
(Fig. 4.2) [1, 3]. cells play a critical role in eradicating infection
36 T.W. Costantini and R. Coimbra

by identifying foreign pathogens (i.e., bacteria) phagocytosing cellular debris and necrotic cells.
through pathogen-associated molecular patterns Macrophages further propagate the inflammatory
(PAMPs), preventing spread of infection, and response by releasing the pro-inflammatory cyto-
destroying pathogens through phagocytosis and kines TNF-α, IL-1, and IL-12. In addition, tissue
cytotoxicity. In the case of major injury, DAMPs macrophages play an important role in the innate
activate the innate immune system to respond to immune system as antigen-presenting cells that
injured cells/tissue through a coordinated cause activation of T cells of the adaptive immune
response that results in cytokine expression, system.
cytotoxicity, and ultimately activates cells of the
adaptive immune system.
4.3.3 Dendritic Cells

4.3.1 Neutrophils Dendritic cells (DCs) are the link between innate
and adaptive immunity. DCs are antigen-­
Neutrophils are the predominant cell type of the presenting cells that serve as strong activators of
innate immune system. Activated neutrophils are the systemic inflammatory response. There are
the primary effector cell in the acute inflamma- several subpopulations of DCs that have different
tory response. These circulating cells respond to tissue distribution and various roles in the inflam-
injury signals by binding to adhesion molecules matory response. DCs are derived from hemato-
expressed on endothelial cells and enter injured poietic stem cells in the bone marrow and can be
tissue by chemotaxis in response to cytokines classified as myeloid DCs or plasmacytoid DCs
such as interleukin-8 (IL-8). After migration to based on lineage and tissue environment. Myeloid
the extracellular matrix in sites of tissue injury, DCs are derived from circulating monocytes, are
neutrophils respond through degranulation and rapidly recruited to sites of injury after major
oxidative burst which is cytotoxic to surrounding trauma, and secrete cytokines including IL-12
cells and is designed to control local tissue injury. that primes T cell activation.
While PMN activation and degranulation plays a
vital role in responding to injured cells and tis-
sue, the release of reactive oxygen species and 4.4  ut Barrier Failure
G
proteases during oxidative burst can be deleteri- and the SIRS Response
ous to the host tissues resulting in organ injury.
Further, recruited neutrophils secrete several pro-­ The gut barrier performs a vital function in the
inflammatory cytokines including TNF-α and innate immune system in preventing toxic lumi-
interferon gamma (IFN-γ) that further drive the nal factors from accessing protected layers of the
inflammatory response. intestine [5]. It is well recognized that the loss of
intestinal barrier integrity is the central culprit in
the development of SIRS following injury.
4.3.2 Monocytes/Macrophages Several studies have demonstrated that severe
injury results in compromised intestinal barrier
Monocytes make up a small portion of circulat- integrity that is marked by structural and histo-
ing cells at baseline, representing approximately logical changes within the intestinal epithelium
5–10% of leukocytes in the peripheral blood. The [6–9]. In the gut, a subset of myeloid DCs and
spleen acts as a large reservoir of monocytes that local cytokines control the equilibrium between
are poised to respond to injury or infection by regulatory (Treg) and effector T cells (Th17) and
release into the circulation and trafficking to sites coordinate the balance between tolerance to
of injury. Once recruited to sites of tissue injury, inflammation during homeostasis and an innate
monocytes leave the circulation and mature into immune response that is required to response to
macrophages where they play a critical role in injury [10, 11]. In homeostasis, resident gut DCs
4  Response to Major Injury 37

drive the differentiation of naïve CD4+ T cells to inflammation and may be another link between
Tregs, which maintain tolerance through release coagulation and inflammation in the SIRS
of TGF-β and subsequent release of tolerant response to injury.
CD103+ DCs into the mesenteric lymph [12].
After gut barrier failure following injury, pro-­
inflammatory stimuli activate resident gut DCs to 4.6 Complement Activation
produce the pro-inflammatory cytokine IL-6 that
drives the development of pro-inflammatory The complement cascade is a part of the innate
effector Th17 cells [13]. These Th17 cells immune system which responds rapidly after
respond to gut injury through release of IL-17, injury [21]. Activation of the complement system
with increased neutrophil recruitment to the gut also alters the coagulation cascade, linking these
and further release of pro-inflammatory media- two pathways in the response to injury [22].
tors. These gut-derived pro-inflammatory factors Levels of circulating activated complement
are carried through the mesenteric lymph where ­proteins correlate with injury severity, contribute
they propagate the SIRS response by causing to multiple organ failure, and are related to out-
endothelial and red blood cell dysfunction, neu- comes [23, 24]. The complement system is com-
trophil activation, cytokine release, and poten- prised of circulating plasma proteins which are
tially distant organ injury [14]. Therefore, the gut normally in their inactive state. Once activated by
has been termed the “motor” of the SIRS response a stimulus such as the presence of foreign patho-
after injury with numerous preclinical studies gens or tissue trauma, proteins of the comple-
aimed at limiting gut inflammation as a means of ment system become activated. These activated
limiting distant organ injury after major trauma complement proteins are responsible for driving
[15, 16]. the SIRS response through opsonization and
phagocytosis and further cause the recruitment of
other inflammatory cells to the site of tissue
4.5 Coagulation Cascade injury.
The complement cascade can be activated
Acute coagulopathy occurs early after severe through three different pathways. In the classic
injury, with clinically significant coagulopathy pathway, complement proteins are activated by
noted in approximately 25% of patients upon immunoglobulin G (IgG) or IgM bound to an
arrival to the emergency department [17, 18]. In antigen. The classic pathway is also activated by
a multicenter study, an elevated international acute-phase proteins which are produced in
normalized ratio (INR) greater than 1.5 at admis- response to injury. The alternate pathway of com-
sion was associated with an increased risk of plement activation occurs when complement
multiple organ failure and death [19]. Cross-talk binds directly to the PAMPs displayed by bacte-
between inflammation and the coagulation cas- ria, viruses, and fungi and does not rely on anti-
cade can result in a self-perpetuating cycle that bodies binding to the pathogen. The
drives the SIRS response. Platelets become acti- mannose-binding lectin pathway is similar to the
vated by trauma and serve as a source of pro- classic pathway of complement activation.
inflammatory mediators that activate innate Mannose-binding lectin is produced by the liver
immune cells and drive the SIRS response. in response to injury and infection and binds to
Similarly, tissue injury and DAMP release after the surface of invading pathogens, initiating the
trauma cause activation of endothelial cells and complement cascade. This system is highly regu-
immune cells which results in platelet activity lated, as activation of the complement cascade
and further drives the coagulation cascade. Acute can be damaging to host tissues. Some evidence
coagulopathy after trauma is also associated suggests that activation of the mannose-binding
with activation of the protein C pathway [20]. lectin pathway may lead to MOF in patients with
Activated protein C is a known mediator of sterile inflammation [25].
38 T.W. Costantini and R. Coimbra

4.7 Multiple Organ Failure 6. Bansal V, Costantini T, Kroll L, Peterson C, Loomis

W, Eliceiri B, et al. Traumatic brain injury and intesti-
nal dysfunction: uncovering the neuro-enteric axis.
The exaggerated host response to the severe J Neurotrauma. 2009;26:1353–9.
injury can lead to significant tissue injury, end 7. Costantini TW, Peterson CY, Kroll L, Loomis WH,
organ dysfunction, and ultimately multiple organ Putnam JG, Wolf P, et al. Burns, inflammation, and
intestinal injury: protective effects of an anti-­
failure (MOF). MOF is defined as progressive,
inflammatory resuscitation strategy. J Trauma.
potentially reversible dysfunction of two or more 2009;67:1162–8.
organ systems including the lung, liver, gastroin- 8. Yu LC, Flynn AN, Turner JR, Buret AG. SGLT-1-­
testinal tract, renal, and hematologic systems. mediated glucose uptake protects intestinal epithelial
cells against LPS-induced apoptosis and barrier
Post-injury MOF is the most significant cause of
defects: a novel cellular rescue mechanism? FASEB
late deaths in trauma patients [26–28]. Risk for J. 2005;19:1822–35.
MOF is related to the extent of injury and can be 9. Amasheh M, Fromm A, Krug SM, Amasheh S,
predicted early, where early cytokine production Andres S, Zeitz M, et al. TNFalpha-induced and
berberine-­antagonized tight junction barrier impair-
following injury may predict patients at risk for
ment via tyrosine kinase, Akt and NFkappaB signal-
developing MOF [29]. There are several factors ing. J Cell Sci. 2010;123:4145–55.
that can identify patients at risk of developing 10. Weaver CT, Hatton RD. Interplay between the TH17
MOF. Scoring systems performed in the emer- and TReg cell lineages: a (co-)evolutionary perspec-
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gency department at the time of admission have
11. Omenetti S, Pizarro TT. The Treg/Th17 axis: a

the ability to predict the development of MOF dynamic balance regulated by the gut microbiome.
within 7 days of hospitalization after injury [30]. Front Immunol. 2015;6:639.
Organ failure scores, such as the Sequential 12. Morishita K, Coimbra R, Langness S, Eliceiri BP,
Costantini TW. Neuroenteric axis modulates the bal-
Organ Failure Assessment score (SOFA score) or
ance of regulatory T cells and T-helper 17 cells in the
the Denver MOF score, can be utilized to describe mesenteric lymph node following trauma/hemor-
organ failure in critically ill patients and can pre- rhagic shock. Am J Physiol Gastrointest Liver Physiol.
dict mortality with mortality rates directly related 2015;309:G202–8.
13. Heiseke AF, Jeuk BH, Markota A, Straub T, Lehr HA,
to the number of organ systems which have failed
Reindl W, et al. IRAK1 drives intestinal inflammation
[31]. ICU patients that develop MOF have a by promoting the generation of effector Th cells with
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 Defining the Lethal Triad
5
Mitchell Dyer and Matthew D. Neal

5.1 Introduction trauma is a consequence of iatrogenic factors and

resuscitation. Previous resuscitation strategies
Worldwide, trauma leads to millions of deaths involving large volumes of crystalloid and/or
and severe injuries each year. Analysis of the packed red blood cells in isolation (without blood
leading causes of death in trauma patients reveals component therapy) led to a dilutional coagulop-
that hemorrhage is one of the most common and athy. Although this remains a clinically important
preventable etiologies in the acute period [1]. For challenge, modern resuscitation strategies that
those that survive the initial insult, the cause of limit crystalloid and focus on 1:1:1 ratio-based
both morbidity and late mortality after trauma is, transfusion have limited this component substan-
in part, excessive inflammation and a vicious cas- tially [3, 4]. In this chapter, we will focus on the
cade of coagulation abnormalities. Thus, trau- previously named “lethal triad” which links
matic hemorrhage can be broadly categorized coagulopathy with hypothermia and acidosis as
into two groups: (1) early surgical bleeding and major contributors to the ongoing hemorrhage
(2) coagulopathy. Surgical bleeding is secondary despite control of surgical bleeding.
to the injury (e.g., splenic laceration, femur frac-
ture), and treatment often involves mechanical
control through surgical or interventional proce- 5.2 History
dures. Coagulopathy following trauma presents
in two distinct forms. It is now widely recognized Coagulation abnormalities have long been
that severe injury is characterized by a unique, described in both shock and trauma. A biphasic
endogenous coagulopathy, referred to as the response of initial hypercoagulability followed
acute traumatic coagulopathy (ATC) that may be by hypocoagulability was reported in experi-
present on admission in as many as 30% of mental animal studies and humans in hemor-
injured patients [2]. This devastating condition rhagic shock [5–7]. Simmons and McNamara
presents a major obstacle in the care of trauma both reported clinical series of coagulopathy
patients and is an evolving area of active research. following massive trauma in Vietnam soldiers
The second form of coagulopathy following [8, 9]. As well, coagulation abnormalities have
been reported with isolated traumatic head
M. Dyer, MD • M.D. Neal, MD (*) ­injuries [10].
Division of Trauma and Acute Care Surgery, In 1982, Kashuk et al. coined the phrase
Department of Surgery, University of Pittsburgh
School of Medicine, Pittsburgh, PA, USA
“bloody vicious cycle.” They reported that in
e-mail: nealm2@upmc.edu patients that suffered a major abdominal vascular

© Springer International Publishing AG 2017 41

H.-C. Pape et al. (eds.), Damage Control Management in the Polytrauma Patient,
DOI 10.1007/978-3-319-52429-0_5
42 M. Dyer and M.D. Neal

injury, most mortalities were attributed to hemor- move straight to a coagulopathy that independent
rhage; however, a significant percent of those of other factors. In this chapter we will review the
patients had control of the surgical bleeding yet components of the lethal triad with a focus of the
continued to exsanguinate seemingly secondary coagulopathy component, its underlying mecha-
to an uncontrollable coagulopathy [11]. This nism, identification of coagulopathy in the trauma
uncontrollable coagulopathy, along with syner- patient, and treatment options.
gistic effects from hypothermia and acidosis,
constitutes the “bloody vicious cycle” or other
times called the lethal triad (Fig. 5.1). It is impor- 5.3 Hypothermia
tant to recognize, however, that our understand-
ing of the clinical problem has evolved Hypothermia in trauma patients can result from a
substantially and that although hypothermia and multitude of reasons including alcohol intoxica-
acidosis likely contribute to ongoing coagulopa- tion, central nervous system injuries resulting in
thy, there is very clearly a unique endogenous deranged thermoregulation, fluid resuscitation,
coagulopathy that occurs in a subset of trauma and likely most importantly skin and body cavity
patients. As such, the bloody vicious cycle may exposure to the surrounding environment. In one
still exist for some patients; however, it is clear series 66% of severely injured trauma patients
that some unfortunate, severely injured patients were hypothermic defined as a core temperature
<36 °C, on admission to the emergency depart-
ment [13]. Furthermore the authors found the
“The bloody vicious cycle”
lowest recorded temperature was significantly
Major torso trauma lower in patients who died compared to those
who lived (32.9 °C vs. 35 °C). As well, hypother-
mia was associated with increased time spent in
Active the field, increased injury severity score (ISS),
hemorrhage
and increased volume of blood transfusions.
Cellular Jurkovich et al. demonstrated that hypothermia
Latrogenic shock was independently associated with mortality, and
Progressive factors
coagulopathy in patients whose core temperature fell to below
32 °C, there was not a single survivor [14]. While
it is clear that patients who are severely hypother-
Core
hypothermia mic do not do well, it is unclear whether the
Tissue hypothermia results from the injury or the hypo-
injury thermia leads to poorer outcomes.
Metabolic
acidosis It has been postulated that the hypothermic
effect on coagulopathy results from processes
such as depression of enzyme function and plate-
Contact
activation let dysregulation [15–17]. In vitro studies that
Massive have analyzed the coagulation cascade found that
transfusion
enzyme function, platelet adhesion, and aggrega-
Clotting factor
deficiencies tion were impaired below 33 °C [18]. A series of
Pre-existing trauma patient blood samples were analyzed with
diseases
thromboelastography (TEG) that was adjusted to
Fig. 5.1  “The bloody vicious cycle” is hypothesized to patient core temperature to identify the effects of
result from multiple factors that ultimately lead to acido- hypothermia on coagulation [19]. Interestingly,
sis, hypothermia, and coagulopathy which in turn results
in ongoing hemorrhage despite surgical control of bleed-
TEG results demonstrated that most patients,
ing from organ injury (Reprinted with permission from regardless of core temperature, were
Moore [12]) ­hypercoagulable on presentation, although once
5  Defining the Lethal Triad 43

clot was formed, clot propagation was found to reported that at a pH of 7.0 compared to 7.4, fac-
be slower in the most hypothermic (33.0–33.9 °C) tor VIIa activity was significantly decreased in an
patients. Platelet function during the clot polym- in vitro model [25]. In a pig model, acidosis was
erization phase and overall clot strength were found to decrease plasma fibrinogen levels and
also found to be less in patients with lowest core decrease thrombin generation; however, in this
temperatures. While coagulation abnormalities same model when the acidosis was corrected
can be shown in severe hypothermia both in vitro with bicarbonate, the coagulopathy was not cor-
and in vivo, it is not clear whether the effects of rected as well [26, 27]. This suggests the effect of
hypothermia on coagulation are significantly rel- acidosis on coagulation may not be reversible or
evant to most trauma patients. Still, rewarming that acidosis and coagulopathy may be present
measures should be taken in all hypothermic but not directly linked. As with hypothermia the
trauma patients to counter whatever contribution clinical contribution of acidosis to the net coagu-
hypothermia adds to coagulopathy. lopathy observed in trauma is difficult to fully
assess. While it appears that the effect is likely
mild until the acidosis is severe (<7.2), it cannot
5.4 Acidosis be ignored when treating the critically injured
trauma patient.
Trauma patients most often become acidotic sec-
ondary to hypoperfusion resulting from massive
hemorrhage. This hypoperfusion leads to a switch 5.5 Coagulopathy
from aerobic to anaerobic metabolism at a cellu-
lar level ending in a buildup of excess lactate. In The third component of the lethal triad is coagu-
1964, Broder et al. demonstrated that an excess lopathy or the “nonsurgical” bleeding in criti-
lactate level was associated with an increased cally ill trauma patients. Traditional thought had
risk of death and was a marker of progression of been coagulopathy developed secondary to coag-
shock [20]. In a series of trauma patients admit- ulation factor loss in hemorrhage, dilutional
ted to the ICU, it was found that inability to clear effects from crystalloid resuscitation, and the
lactate at 48 h was associated with a significant contributing effects of hypothermia and acidosis
risk of death [21]. Acidosis is associated with as previously discussed [28]. This concept came
poor outcomes in trauma patients, but the role in under scrutiny due to observational reports of
the triad is less defined. coagulopathy existing early after the sustained
Acidosis has been implicated in worsening the injury and prior to aggressive resuscitative
coagulopathy seen in severely injured trauma efforts. In 2003, the term acute traumatic coagu-
patients. In fact, acidosis has been found to be an lopathy (ATC) was coined [29]. Defined by eleva-
independent risk factor in developing life-­ tions in prothrombin time (PT), activated partial
threatening coagulopathy in massively transfused thromboplastin time (aPTT), and thrombin time
trauma patients [22]. Dunn et al. demonstrated (TT), it was discovered that nearly 25% of
impaired hemostasis when blood pH dropped to severely injured trauma patients demonstrated
less than 7.2 in an animal model [23]. TEG analy- coagulopathy on arrival to the emergency depart-
sis of blood samples with altered pH levels dem- ment. Importantly, these patients received mini-
onstrated abnormal polymerization of clots and mal prehospital fluid administration, and, on
decreased time to clot development at severely univariate analysis, there was no correlation
depressed levels (pH = 6.8) [24]. Individual clot- between the amount of fluid given and develop-
ting factor functions can be directly impaired by ment of coagulopathy. Around the same time,
acidosis. Factor VII is crucial in the initiation of MacLeod et al. found a similar incidence of
clotting and formation of the platelet plug and coagulopathy in trauma patients on arrival to the
recombinant forms have previously been used to emergency department [30]. Further analysis of
treat coagulopathy in trauma patients. Meng et al. this patient population revealed coagulopathy,
44 M. Dyer and M.D. Neal

defined by elevated PT or aPTT, was an indepen- Severe trauma,

dent predictor of all-cause mortality with hemorrhagic shock
increased adjusted odds of mortality by 35% and
326%, respectively. Together these two landmark
studies redefined the thought process of coagu-
Hypoperfusion
lopathy in trauma. Because these coagulation
abnormalities were identified on arrival to the
hospital and without significant resuscitation
prior to lab draws, it appears that there is an aPC Plasmin
endogenous coagulopathy associated with severe
trauma. This inherent coagulopathy has been
Factors V & VIII PAI-1 Hyperfibrinolysis
referred to by different names including acute
coagulopathy of trauma (ACOT), acute coagu-
lopathy of trauma-shock (ACOTS), early trauma-­
induced coagulopathy (ETIC), and
trauma-induced coagulopathy (TIC) in addition ATC
to ATC [31–34]. Going forward we will refer to
this endogenous coagulopathy as ATC.
While there has been a shift in the understand- Fig. 5.2  Mechanisms of acute traumatic coagulopathy
(ATC): The aPC and hyperfibrinolysis pathways are lead-
ing of ATC, the underlying mechanism has yet to
ing hypothesis for the underlying mechanism of ATC. As
be elucidated. Initial work in shock and observa- shown here there is cross talk between pathways, and
tions of coagulopathy in military trauma victims there is likely multiple pathways contributing to develop-
attributed the hypocoagulable state to onset of ment of ATC. As well, hypoperfusion is a key component
to development of ATC; when absent in many studies,
disseminated intravascular coagulation (DIC) [5,
ATC does not develop. aPC activated protein C, PAI-1
8, 35, 36]. Others have argued that while DIC and plasminogen activator inhibitor 1, ATC acute traumatic
ATC share similar changes, they are, in fact, dis- coagulopathy
tinct entities as ATC does not truly meet DIC cri-
teria, nor do most trauma patients exhibit
disseminated clot burden [37–39]. Two current activation of protein C, and bleeding resulting
leading hypotheses are (1) the activated protein C from the downstream effects of the anticoagulant
(aPC) and (2) fibrinolysis pathways (Fig. 5.2). properties exerted by aPC. Brohi et al. found in
trauma patients with tissue hypoperfusion,
defined by an elevated base deficit, that low pro-
5.5.1 Activated Protein C tein C levels were associated with prolonged PT
and aPTT values [41]. Accordingly they also
Protein C is a protease that plays an important found in the same group of patients high levels of
role in normal hemostasis. It is activated by a thrombomodulin, low PAI-1, and high D-dimer
complex reaction that is dependent on thrombin, levels that all suggest activation of protein C. In
thrombomodulin, and the endothelial protein C this study, low protein C levels were associated
receptor [40]. Activation of protein C (aPC) with with increased mortality. These observations in
cofactor protein S leads to inactivation of factors trauma patients were taken to the laboratory, and
V and VII in the coagulation cascade. Another in a mouse model of trauma and shock, the devel-
anticoagulant effect of aPC is inhibition of plas- opment of coagulopathy was associated with
minogen activator inhibitor 1 (PAI-1), which then increased aPC levels [42]. Interestingly, when
results in increased active plasmin and increased mice were pretreated with an antibody that selec-
fibrinolysis (Fig. 5.2). tively inhibits the anticoagulant properties of
The aPC hypothesis proposes that severe aPC, the coagulopathy was reversed; although
injury and shock leads to tissue hypoperfusion, when an antibody that completely blocks the
5  Defining the Lethal Triad 45

function of aPC was used, there was 100% mor- reduced fibrinolysis and/or a reduction in bleed-
tality in the mice. Taken together, these data sug- ing – this will be discussed further in the treat-
gest that aPC has multiple roles in the severely ment section of this chapter. As with the aPC
injured trauma patients, some of which are pro- pathway, tissue hypoperfusion was found to be a
tective. Later work by Cohen et al. that directly critical component in patients with hyperfibri-
measured aPC levels in human trauma patients nolysis. On the other hand, recent work from
found that increased levels of aPC were associ- Moore et al. stratified three fibrinolytic pheno-
ated with increased mortality, transfusion require- types (>3% hyperfibrinolytic, 0.81–2.9% physi-
ments, and organ injury [43]. Central to all of the ologic, <0.08% fibrinolytic shutdown) and found
findings discussed above is tissue hypoperfusion. increased mortality with both hyperfibrinolysis
Neither in humans nor mice was coagulopathy and fibrinolysis shutdown [48]. Patients with
noted in those that did not exhibit evidence of hyperfibrinolysis were dying from hemorrhage,
hypoperfusion. The link between hypoperfusion whereas mortality associated with fibrinolysis
and activation of protein C is yet to be shutdown was secondary multisystem organ fail-
elucidated. ure. The mechanism underlying this remains to
be elucidated, but the ability to identify and ulti-
mately treat these different phenotypes in trauma
5.5.2 Fibrinolysis patients will be a key future area of research.
While there is evidence mounting for many dif-
Fibrinolysis is a normal part of the homeostasis ferent hypotheses of the mechanism of ATC, it is
in coagulation; however, excess breakdown of more likely that each hypothesis contributes to
normal clot production can lead to or exacerbate the overall pathophysiology. This can be easily
ongoing hemorrhage. It is hypothesized in ATC seen between the aPC and hyperfibrinolysis path-
that severe injury leads to tissue hypoperfusion, ways. As described earlier aPC has been shown
activation of plasmin, and hyperfibrinolysis [44]. to inhibit PAI-1 and therefore creating more
Using TEG analysis, fibrinolysis was identified available plasmin and, in theory, increased fibri-
in 34% of patients requiring massive transfusion nolysis. It is likely that there is cross talk between
[45]. Fibrinolysis was associated with tissue multiple pathways that contribute to ATC. What
hypoperfusion (elevated lactate levels) and is clear is the importance of tissue hypoperfusion
increased transfusion requirements, and logistic to the development of ATC regardless of the path-
regression analysis revealed fibrinolysis as a pre- way that leads to it. It is also important to note the
dictor of hemorrhage-related death in the same multiple functions of many of these pathways as
group of patients. In a series of nearly 2,000 evidenced by the 100% mortality rate in mice
trauma patients, hyperfibrinolysis was only found when there was complete blockade of aPC. From
in 2% of victims but was associated with mortal- the available literature, it appears that while the
ity of 76% compared to 10% in patients who did understanding of ATC is progressing, there is still
not have hyperfibrinolysis [46]. Further work a large gap in knowledge and that the answer is
with TEG analysis in severely injured trauma likely to come from multiple pathways rather
victims found a fibrinolysis level of 3% or greater than a single one.
to be significantly associated with a higher risk or
hemorrhage-related death [47]. The CRASH-2
study demonstrated that tranexamic acid, a drug 5.5.3 T
 raumatic Brain Injury-­
designed to inhibit fibrinolysis, was associated Associated Coagulopathy
with decreased mortality, lending further hypo-
thetical support to the important role of hyperfi- The association between traumatic brain injury
brinolysis. Despite the positive findings in terms (TBI) and coagulopathy has been well
of reduced mortality, it is unclear that the benefit documented, and the pathophysiology is
­
of tranexamic acid in CRASH-2 was due to believed to be secondary to release of tissue
46 M. Dyer and M.D. Neal

factor into systemic circulation after break- that defined ATC used elevated PT and aPTT
down of the blood-­brain barrier, a period of ­values to define coagulopathy [29, 30]. However,
microvascular thrombosis leading to coagulant multiple studies have shown PT/INR to be a poor
factor consumption, and then coagulopathy, predictor of coagulopathy in addition to the fact
much like a DIC picture [49]. In 2008, a sys- that elevation of PT or aPTT can be associated
tematic review, a prevalence of ~33% for coag- with a pro-thrombotic state [56–58]. As well,
ulopathy following TBI, was identified, and most standard coagulation tests only evaluate
this was independently associated with either a single factor or one side of the coagula-
increased mortality [50]. A recent systematic tion pathway, whereas trauma patients suffering
review of isolated TBI and coagulopathy found from hemorrhage likely have multiple abnormal-
a prevalence of ~35% [51]. However, these ities, and therefore standard PT and aPTT are
reviews are difficult to interpret as the defini- poor predictors of bleeding [59]. Others raise
tions for coagulopathy were heterogeneous in issue that standard coagulation tests do not
both reviews, and they include many studies account for fibrinolysis or platelet function and
that predate the studies by Brohi and MacLeod therefore ignore an important part of the hemo-
that defined ATC. Therefore, TBI ­ certainly static mechanism which limits the usefulness in
appears to be associated with coagulopathy, but guiding treatment [60]. Finally, these standard
its contribution, if any to the pathophysiology tests are plasma-based assays and lack the ability
of ATC, remains uncertain. As well, a recent to account for other critical components of whole
review of TBI did not find a greater degree of blood to coagulation.
coagulopathy after isolated TBI compared to A growing area of research in trauma
injury to other body regions [52]. coagulopathy and resuscitation is the use of
­
thromboelastography (TEG) and rotational
thromboelastometry (ROTEM) to assess coagu-
5.6 ATC Identification lation status (Table 5.1 and Fig. 5.3). These simi-
lar, but different, machines use whole blood and
As ATC is associated with increased mortality in analyze the viscoelastic properties as the blood
the trauma patient, the ability to correctly iden- goes through a clot formation and dissolution
tify and therefore treat has become an increasing (fibrinolysis) [62]. The popularity of TEG/
important topic of research. In the massive trans- ROTEM is that functional information about clot
fusion literature, which affects only approxi- development and strength can be obtained,
mately 5% of all trauma patients, there have been whereas traditional coagulation tests only are
retrospective studies performed in attempts to able to provide information on levels in circula-
develop scoring systems to predict patients who tion. While TEG/ROTEM have been in clinical
will require massive transfusion [53–55]. On the use for 60 years in cardiac and liver transplant
other hand, there is a paucity of standardized surgery and have been shown to decrease blood
tests or algorithms for the “identification” of product transfusions, its use in trauma is in its
ATC. The initial studies by Brohi and MacLeod relative infancy [63–65].

Table 5.1  Thromboelastography values: typical readout from a TEG will provide many parameters of the coagulation
status of a patient and allows the clinician to determine what component therapy to administer to the patient based on
the individual parameter results
Value Description Normal range
Reaction time (R) Time to thrombin generation 4–9 min
Kinetics (K) Measure of time to reach 20 mm amplitude 1–4 min
Alpha angle (α) Rate of clot formation due to fibrin cross-linking 47–74°
Maximum amplitude (MA) Clot strength (80–80% platelets; 10–20% fibrin) 55–73 mm
LY 30 Fibrinolysis 0–7.5%
5  Defining the Lethal Triad 47

Fig. 5.3  Example of a normal

TEG tracing. Values correspond Coagulation Fibrinolysis
to Table 5.1 (Image adapted Clotting (LY)
Clot
from Nystrup et al. [61]) time kinetics
(R)

Platelet function
(MA)

Early animal work suggested that TEG was patients. A Cochrane review of the literature for
better at identifying clinically relevant TEG and ROTEM was not able to identify any
­coagulopathies than PT, aPTT, or activated clot- evidence to support the accuracy of TEG and lit-
ting time (ACT). Pigs subjected to hypothermia, tle evidence for ROTEM and suggested these
hemorrhage, or both had baseline and post-inter- tests be used only on a research basis, although
vention PT, aPTT, ACT, and TEG analysis per- one of the authors of this chapter (MDN) pub-
formed, and it was found that PT, aPTT, and ACT lished a rebuttal as an addendum to the Cochrane
were not sensitive in detecting the coagulation review highlighting the deficits in the analysis
abnormalities that TEG analysis was able to iden- [69]. On the other hand, a recent consensus con-
tify [66]. The ability to use TEG as a point of care ference held to determine guidelines for the use
test has been investigated as well. Cotton et al. of viscoelastic testing in trauma patients sup-
prospectively performed rapid-TEG (r-TEG) on a ported the use of viscoelastic testing in the early
series of trauma patients and found that r-TEG phases of resuscitation given the strong associa-
values not only correlated with traditional coagu- tion between abnormal results and increased
lation lab tests but all results from the r-TEG mortality and need for massive transfusion [70].
were available within 15 min compared to 48 min As well, it was recommended viscoelastic testing
for PT, INR, and aPTT [67]. Linear regression be used to determine administration of antifibri-
analysis also found that among these patients, nolytic therapy as TEG and ROTEM are cur-
r-TEG results were predictive of transfusion rently the only practical options of detecting
requirement. In a series of nearly 2,000 trauma hyperfibrinolysis rapidly early in the trauma
patients, admission r-TEG data was obtained and resuscitation process. Holcomb and colleagues
compared to conventional coagulation tests have suggested that TEG replaces the use of
(CCT) including PT, aPTT, INR, platelet count, admission INR in trauma patients [68].
and fibrinogen levels and found to correlate well At this time viscoelastic testing either in the
with the CCTs. However, r-TEG data was supe- form of TEG or ROTEM appears to be a promis-
rior in predicting the need for red blood cell, ing new tool in the armamentarium of the trauma
plasma, and platelet transfusions [68]. surgeon despite the lack of general consensus on
The evidence to support TEG and r-TEG is how best to utilize it. The American College of
encouraging as a new avenue to rapidly identify Surgeons Resources for Optimal Care of the
patients with ATC. However, almost all the litera- Injured Patient 2014 (sixth edition) recommends
ture is retrospective in nature, and importantly that thromboelastography should be available at
while r-TEG values have been found to be pre- level I and II trauma centers. Further research,
dictive of transfusion, there are no standardized specifically prospective trials, are needed to
algorithms or data to guide how much to trans- clearly identify threshold levels for transfusion,
fuse based on cutoff levels. As well, there is no how much to transfuse, and how best to use vis-
current evidence that has utilized TEG to follow coelastic testing to follow the resuscitation pro-
response to resuscitative efforts in trauma cess and adjust accordingly.
48 M. Dyer and M.D. Neal

5.7 Treatment A growing interest in the literature is “goal-­

directed resuscitation” where rapid viscoelastic
Severely injured trauma patients suffering from testing is used to guide the treatment and resusci-
hemorrhage and coagulopathy are at an tation of coagulopathic and massively bleeding
increased risk of mortality, and therefore patients rather than empiric, fixed ratios of blood
prompt resuscitation and treatment are of products. Observational data have demonstrated
upmost importance. There has been a recent that MTP did not lead to correction of coagulopa-
shift in focus in the resuscitation of these thy based on serial viscoelastic test results nor
severely injured patients from initial IV fluids correction of hypoperfusion as measured by lac-
to blood component therapy [3, 71, 72]. In tate levels [78]. One institution reviewed their
addition to the focus of early blood component pre- and post-MTP mortality rates, where pre-­
utilization, there has been literature published MTP treatment of severely injured trauma
to suggest the ratio in which these products patients had been guided by TEG analysis. They
administered affect outcomes in these patients, found that in patients requiring 6 U PRBC and in
namely, higher ratios of platelets, plasma, and blunt injury, TEG and MTP were equivalent. In
cryoprecipitate to PRBC that are associated penetrating injury or patients requiring more than
with improved mortality [73, 74]. The prospec- 10 U PRBC, mortality rates were lower with
tive, observational, multicenter, major trauma TEG-driven treatment compared to MTP [79].
transfusion (PROMMTT) study followed the The use of TEG to guide fibrinogen replacement
transfusion practices and tracked patient out- and administration of prothrombin concentrate
comes in ten level 1 trauma centers across the complex has been associated with lower mortal-
United States and found that higher plasma/ ity rates observed than what would be predicted
PRBC and higher platelet/PRBC ratios were based on the trauma injury severity score (TRISS)
associated with decreased mortality in the first and the revised injury severity classification
6 h following admission [75]. Even after the (RISC) [80]. Proponents of “goal-directed resus-
results from the PROMMTT trial, the question citation” argue that, as opposed to MTP, TEG-­
of the ideal ratio existed as others had reported driven resuscitation is data driven, corrects
different optimal transfusion ratios [76, 77]. underlying coagulopathy, addresses ATC, and
This was investigated with a large, multicenter, does not follow a “one-size-fits-all” approach
randomized clinical trial, the pragmatic, ran- [81, 82]. As appealing as “goal-directed resusci-
domized optimal platelet and plasma ratios tation” appears, it is important to note that there
(PROPPR) study, that compared 1:1:1–1:1:2 is limited data to this approach, algorithms are
(plasma/platelet/PRBC) and found that the institution dependent, and further studies need to
1:1:1 group had more patients achieve hemo- be performed before full recommendations can
stasis and less die from hemorrhage without be given on this approach [83]. The authors’ insti-
significant transfusion-­related events [4]. While tution has recently implemented a TEG-based
adopted at many centers prior to publication, MTP to guide resuscitation for massively bleed-
results of the PROPPR study confirm and pro- ing patients at the University of Pittsburgh
vide the basis for adoption of massive transfu- Medical Center (UPMC) (Fig. 5.4).
sion protocols (MTP) to treat trauma patients A final active area of investigation is the use of
suffering from massive hemorrhage. However, antifibrinolytic agents in severely injured trauma
it is important to recognize that the PROPPR patients. As discussed earlier, hyperfibrinolysis
trial failed to show a significant difference in has been implicated in ATC and is able to be
the primary endpoints of 24 h and 30-day mor- identified via viscoelastic testing. Tranexamic
tality comparing 1:1:1–1:1:2 ratios. As such, acid (TXA), an antifibrinolytic agent, is a syn-
the “ideal” ratio is unknown, although a clear thetic analog to the amino acid lysine that binds
preponderance of the evidence suggests and inhibits the actions of plasminogen. It has
improved outcomes with higher ratios of proven transfusion benefits and a proven safety
plasma and platelets. profile [84]. The effects of tranexamic acid in
5  Defining the Lethal Triad 49

Fig. 5.4 Goal-directed
transfusion algorithm that TEG-guided MTP resuscitation
demonstrates the different
approach to resuscitation of a
trauma patient in hemorrhage Massive
transfusion
shock compared to 1:1:1 in
protocol
massive transfusion protocols.
ACT activated clotting time,
MA maximum amplitude,
FFP fresh frozen plasma, FFP:PLT: PRBC
Plt platelets, Cryo 1:1:1
Ca Chloride 1g
cryoprecipitate, TXA
tranexamic acid, PRBC packed
red blood cells (Image used
with permission from
University of Pittsburgh Rapid-TEG
Medical Center Department
of Surgery)

ACT > 128 s MA < 52 mm Angle < 60° LY30 > 3%

FFP PLT *CRYO TXA

128-160: 2 units 46-52: 1 dose 1 dose (4 pool) 1 g bolus. 1 g gtt
161-178: 3 units 41-45: 2 dose
>178: 4 units < 41: 3 dose

Re-assess with rapid-TEG

* If angle and ACT or MA abnl, correct ACT

and MA first. This may fix the angle

bleeding trauma patients or patients deemed high noted decreased coagulopathy in patients who
risk of bleeding were examined in the CRASH-2 received TXA, but there was a higher rate of vas-
study, a randomized, placebo-controlled trial cular occlusive events in the TXA patients. TXA
[85]. It was found that early administration of appears to have a survival benefit to critically
TXA was associated with decreased risk of all-­ injured trauma patients; however, it is important
cause mortality and death from bleeding, while to note the data was obtained with the administra-
no increased risks of vascular occlusive events tion of TXA left to clinical judgment, not based
were found. TXA was then studied in the military on identification of hyperfibrinolysis. Therefore,
population in the MATTERs study, a retrospec- there may be other benefits of TXA such as anti-­
tive study in the administration of TXA in severe inflammatory properties, or there may be an even
combat injuries [86]. As with the CRASH-2 greater benefit in patients identified via TEG/
study, a survival benefit was identified in those ROTEM to be hyperfibrinolytic. As well, TXA
who received TXA, and subgroup analysis dem- may not be appropriate in all patients as argued
onstrated an even larger benefit in patients requir- by Moore and colleagues after they identified the
ing massive transfusion. The MATTERs trial also importance of fibrinolysis shutdown [48].
50 M. Dyer and M.D. Neal

Conclusion trauma: the PROPPR randomized clinical trial. JAMA.

2015;313(5):471–82. doi:10.1001/jama.2015.12.
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 Part II
General Treatment Principles
 Damage Control Resuscitation
6
Eric J. Voiglio, Bertrand Prunet, Nicolas Prat,
and Jean-Stéphane David

6.1 Introduction divided in two steps: while bleeding is ongoing

and once bleeding has been stopped.
Damage control resuscitation (DCR) for trauma,
initially described to address the entire lethal
triad immediately upon admission to a combat 6.1.1 Physiological Bleeding
hospital before damage control surgery (DCS) Control
[1], is now accepted as part of an integrated
approach DCR-DCS from point of wounding to When bleeding occurs, the baroreceptors located
definitive treatment [2]. Therefore, DCR can be in the aortic arch and carotid sinus detect the drop
in arterial pressure. This information is transmit-
ted to the brain stem, which immediately
E.J. Voiglio, MD, PhD, FACS, increases sympathetic tone [3]. This increased
FRCS, FEBSEmSurg sympathetic tone causes tachycardia (oxygen
Department of Surgery, Unit of Emergency Surgery, transportation is ensured by less blood that circu-
Centre Hospitalier Lyon-Sud, UMR T9405, Faculté
lates faster) and vasoconstriction which favours
de Médecine Lyon-Est, Université
Claude Bernard Lyon1, 69495 Pierre-Bénite, France the blood circulation of the heart and brain at the
e-mail: eric.voiglio@chu-lyon.fr expense of all other organs and tissues (gut, kid-
B. Prunet, MD, PhD ney, muscle and skin). Vasoconstriction at the
Department of Anesthesiology – Intensive Care – bleeding site decreases bleeding flow and allows
Burn Unit, Sainte Anne Military Teaching Hospital, platelets and the activated coagulation factors to
Boulevard Sainte Anne, 83000 Toulon, France
seal the leak by a vascular clot [4] (Fig. 6.1).
e-mail: bertrand.prunet@intradef.gouv.fr
Fibrinolysis regulates coagulation [5] and pre-
N. Prat, MD, PhD
vents vascular occlusion. In favourable cases, the
War-Related Trauma Unit, French Armed Forces
Institute of Biomedical Research, bleeding has stopped or slowed. In unfavourable
91220 Bretigny sur Orge, France cases, because the vascular breach is too large or
e-mail: nicolas-j.prat@intradef.gouv.fr the bleeding sites are multiple, the trauma patient
J.-S. David, MD, PhD (*) is in a situation where the coagulation factors
Department of Anesthesiology and Critical Care have been consumed, fibrinolysis is activated [6],
Medicine, Centre Hospitalier Lyon Sud, Faculté de
Médecine Lyon Est, Université Claude Bernard Lyon 1,
a large volume of blood has been lost, tachycar-
69495 Pierre-Bénite, France dia and vasoconstriction are not sufficient to
e-mail: js-david@univ-lyon1.fr compensate for blood loss and therefore the

© Springer International Publishing AG 2017 57

H.-C. Pape et al. (eds.), Damage Control Management in the Polytrauma Patient,
DOI 10.1007/978-3-319-52429-0_6
58 E.J. Voiglio et al.

Major blood loss

Baroreceptors
Stop the
Volume receptors
bleeding

Epinephrine Less blood flow and

Maintain lower pressure
Peripheral
cerebral vasoconstriction
allow coagulation
perfusion factors to function
properly

Epinephrine
Rénin Adequate
Angiotensin cerebral
Higher heart rate
Aldosterone oxygenation

Discreased
urine output

Fig. 6.1 Simplified pathophysiology of bleeding. blood loss by decreasing the flow and pressure at the
Bleeding induces hypovolaemia and low blood pres- level of the vascular injury leaves time for clot forma-
sure that trigger volume and baroreceptors which, in tion [4]. Increased heart rate allows partial compensa-
turn, transmit the information to the central nervous tion of the loss of oxygen transportation by increasing
system [3]. This results in increased sympathetic vas- the rapidity of red blood cell circulation. At the same
cular tone with the double role of maintaining cerebral time, urine output is decreased by activation of the
blood flow and stopping the bleeding. Vasoconstriction renin-angiotensin-aldosterone complex with the goal of
in the entire organism (except the heart and brain) devi- compensating hypovolemia (E. Voiglio et al. J Visc
ates the blood supply to the brain, while decreasing Surg. 2016,153,13–24)

o­ xygen carrying capacity continues to decrease develops lactic acidosis. Coagulation proteins are
while the bleeding goes on. enzymes that function at 37 °C and pH greater
than 7.2. Under hypothermic and acidotic condi-
tions, the coagulation factors have decreased
6.1.2 T
 he Lethal Triad: activity [8]. Being the blood hypocoagulable, the
Hypothermia, Acidosis bleeding continues later exacerbating hypother-
and Coagulopathy mia and acidosis which themselves exacerbate
coagulopathy: the haemorrhagic vicious circle
Blood loss causes hypothermia, as the blood [9] is constituted which leads to the death of the
plays, among others, the role of a heat transfer trauma patient by exsanguination (Fig. 6.2).
liquid. In the cells of a bleeding trauma patient, While it is very difficult to take out a trauma
because of oxygen deficiency, glycolysis stops at patient from this vicious circle, it is very easy to
the step of pyruvate, which, instead of being con- drive him there. It is sufficient to delay the time
sumed by the Krebs cycle, feeds lactate produc- of haemostasis by a superfluous ‘equipment’ and
tion [7]. Therefore bleeding trauma patient unnecessary imaging investigations (further
6  Damage Control Resuscitation 59

Acute hemorrhage

Stop the
bleeding!

Permissive hypotension IV fluids Transfusions

Coagulopathy
Administer fibrinogen
and other coagulation factors −

Dilution of
coagulation Hypoxia
factors
Combat heat loss Administer O2

Hypothermia

Acidosis

Administer Ca++
Hypocalcemia

Fig. 6.2  Simplified bloody vicious circle. Acute bleeding added to PRBC (acidosis and hypocalcaemia) [10]; con-
triggers cellular hypoxia resulting in metabolic acidosis versely, transfusions can decrease cell hypoxia by improv-
(lactic acid) [7] and hypothermia (decreased metabolism, ing oxygen transportation. The only way to interrupt the
loss of heat transport by hypovolaemia). Hypothermia and vicious circle is to stop the bleeding [11]. Administration of
acidosis lead to coagulopathy because the coagulation fac- oxygen, and limiting IV fluid volume, the strategy of per-
tors are enzymes that do not work efficiently below 34 °C missive hypotension, combating hypothermia, early transfu-
and or pH <7.25 [8]. Coagulopathy exacerbates bleeding. sion of packed red cells, correction of coagulation disorders
Crystalloid volume resuscitation results in dilution of the by supplying the necessary factors and correction of hypo-
coagulation factors, cooling and induction of acidosis by calcaemia can slow down the vicious circle and buy the time
dilution and hyperchloraemia. Transfusions add to the dele- necessary to obtain haemostasis (E. Voiglio et al. J Visc
terious effect of perfusions via the citrate anticoagulants Surg. 2016,153,13–24)

haemorrhage), to dilute his/her blood with perfu- 6.2 Damage Control

sions (hypothermia, dilution acidosis, anaemia, Resuscitation Before
dilution of coagulation factors, hypocoagulabil- Bleeding Is Stopped
ity induced by hydroxyethyl starch [12]) and to
rely on a misleading ‘haemodynamic stability’ 6.2.1 I nitial Assessment: Advanced
artificially achieved by administration of vaso- Trauma Life Support (ATLS)
pressors (lactic acidosis from visceral and periph- Protocol
eral ischaemia). It has been demonstrated for
patients with severe injury of the abdomen and The treatment of bleeding is to stop the bleed-
hypotensive at admission that the probability of ing [11]. Damage control resuscitation is a
death increases by 1% every 3 min spent in the management strategy of which goal is to
shock room [13]. Medico-surgical procrastina- enable survival of the trauma patient until
tion is a great provider of haemorrhagic vicious bleeding is controlled while keeping the risk
circle. of iatrogenicity to a minimum. Damage con-
60 E.J. Voiglio et al.

trol resuscitation is part of ATLS ABCDE pro- 6.2.2 T

 argeted Blood Pressure
tocol [14] that ensures oxygenation of the with Permissive Hypotension
cells: and Restrictive Fluid
Administration
• Airway: airway is most often secured by
orotracheal intubation. When orotracheal Traditional fluid resuscitation in the polytrauma
intubation is impossible and airway has to be patient involved rapid infusion of large volumes
secured, cricothyroidotomy is a DC proce- of clear fluids in an attempt to rapidly restore cir-
dure [15]. C-spine is protected by a cervical culating blood volume and blood pressure. It has
collar. become apparent that this approach has several
• Breathing: trauma patient is given 100% O2. potentially detrimental consequences. The prem-
The SaO2 is monitored. If a pleural effusion ise of permissive hypotension is to keep the
(pneumo- and/or haemothorax) is present, blood pressure low enough to avoid exacerbat-
a chest tube is placed. A sucking ing haemorrhage by hydrostatic clot disruption
­thoracic wound is treated by a vented chest while maintaining adequate end-organ perfusion
seal [16]. [21]. The concept of damage control resuscita-
• Circulation: control of bleeding is initially tion aims to achieve a lower than normal blood
achieved, depending on situations, by direct pressure, also called ‘permissive hypotension’,
pressure eventually enhanced by haemo- and thereby avoid the adverse effects of early
static dressings [17], by tourniquet place- aggressive resuscitation using high doses of flu-
ment [18] or by placement of a pelvic sling ids while there is a potential risk of tissue hypo-
[19]. ECG and blood pressure are monitored perfusion during short periods [22]. Permissive
non-­invasively. Two large-bore intravenous hypotension and restrictive fluid administration
lines or one intraosseous line is placed. are therefore reciprocal components of this
Crystalloid perfusion is started. In case of approach; initial fluid administration is delayed
haemorrhagic shock, permissive hypoten- or minimized, and less aggressive resuscitative
sion and transfusion of red blood cell unit end points are used. A targeted systolic blood
(RBC) (O Rh- then type specific) and early pressure (SBP) of 80–90 mmHg is recommended
plasma administration are recommended until major bleeding has been stopped in the ini-
[14]. A FAST echography is performed to tial phase following trauma without brain injury
look for intraperitoneal bleeding and cardiac [23]. In patients with severe traumatic brain
tamponade [20]. injury (GCS ≤8), maintenance of a mean arterial
• Disability: GCS score is calculated, pupillary pressure ≥80 mmHg is recommended [23]. This
reactivity and symmetry are checked, and approximately equates to aiming for the restora-
focal neurological deficits are searched. tion of a palpable radial pulse. A restrictive fluid
• Exposure: patient’s dresses are removed, and administration strategy is recommended to
a logroll is performed to allow complete achieve target blood pressure until bleeding can
examination including the back. Body tem- be controlled [23]. Such an approach decreases
perature is monitored. both the severity and incidence of dilutional
coagulopathy and as such complements a strat-
Whenever a patient presents haemorrhagic egy of haemostatic resuscitation. Second, this
shock by an active bleeding that cannot be con- reduces fluctuations in, and elevation of, systolic
trolled by external manoeuvres, damage con- blood pressure which may disrupt the premature
trol resuscitation is indicated as long as blood clot forming in areas of injury causing fur-
haemostasis has not been achieved most often ther bleeding. Therefore, it would appear that
by surgery, sometimes by interventional restricting initial IV fluid administration in the
radiology. severely injured should have advantages, and the
6  Damage Control Resuscitation 61

infusion of large volumes of crystalloid is no excessive or left ventricular function is already

longer appropriate. In specific situations, per- impaired, an assessment of cardiac function dur-
missive hypotension may also be of benefit, par- ing the initial ultrasound examination is essential.
ticularly in patients with severe haemorrhage Cardiac dysfunction could be altered in the
from an arterial source. Great caution should be trauma patient following cardiac contusion, peri-
taken in those with concomitant head injury, and cardial effusion or secondary to brain injury with
further work is required to clearly delineate intracranial hypertension. The presence of myo-
which patients might benefit the most from this cardial dysfunction requires treatment with an
approach [24]. inotropic agent such as dobutamine or epineph-
rine. In the absence of an evaluation of cardiac
function or cardiac output monitoring, cardiac
6.2.3 Vasopressor Agents dysfunction must be suspected in the presence of
a poor response to fluid expansion and
Vasopressors may be required transiently to sus- vasopressor.
tain life and maintain tissue perfusion in the pres-
ence of life-threatening hypotension, even when
fluid expansion is in progress and hypovolaemia 6.2.4 Red Blood Cell Transfusion
has not yet been corrected [23]. If used, it is
essential to respect the recommended objectives Blood’s main duty is to carry and deliver oxygen
for SBP (80–90 mmHg) in patients without trau- to tissues. During bleeding, this capacity is
matic brain injury [23]. Norepinephrine is the degraded due to two principal phenomena: drop
agent of choice to restore and maintain target in local blood flow and loss of oxygen carrier,
arterial pressure in haemorrhagic shock. Although haemoglobin. As seen in the previous section,
it has some β-adrenergic effects, it acts predomi- local blood flow can be restored at least tempo-
nantly as a vasoconstrictor. Arterial α-adrenergic rarily by fluid infusion and vasopressors use. This
stimulation increases arterial resistance and may fluid infusion, combined with the physiological
increase cardiac afterload; norepinephrine exerts response to blood loss leading to fluid transfers
both arterial and venous α-adrenergic stimula- from cellular and interstitial compartments to the
tion. Indeed, in addition to its arterial vasocon- vascular bed, causes the dilution of the haemo-
strictor effect, norepinephrine induces globin and the drop in haemoglobin level (Hb).
venoconstriction at the level of the splanchnic However, because the relationship between Hb
circulation in particular, which increases the and adverse outcomes in patient with haemor-
pressure in capacitance vessels and actively shifts rhagic shock has not been assessed yet [28], it is
splanchnic blood volume to the systemic circula- not possible to determine with certitude the opti-
tion [25]. This venous adrenergic stimulation mal Hb in trauma patients.
may recruit some blood from the venous Because no artificial oxygen carrier is avail-
unstressed volume. Moreover, stimulation of able so far, the only way to restore the capability
β2-adrenergic receptors decreases venous resis- of blood to carry oxygen to the tissues is to trans-
tance and increases venous return [25]. Animal fuse RBCs. RBCs are available as packed RBCs
studies that investigated uncontrolled haemor- (PRBCs) from blood banks. The shelf storage
rhage have suggested that norepinephrine infu- time is limited to about 40 days at 4 °C, but the
sion reduces the amount of fluid resuscitation longer the storage, the more lysed RBCs release
required to achieve a given arterial pressure tar- intracellular toxic content as potassium or free
get, is associated with lower blood loss and sig- haemoglobin. This is why a LIFO (last in, first
nificantly improved survival [26, 27]. out) procedure for PRBCs release from blood
Furthermore, because vasopressors may banks needs to be implemented for severely
increase cardiac afterload if the infusion rate is injured patients [29].
62 E.J. Voiglio et al.

In the European guideline, the Hb threshold Hyperfibrinolysis contribution to ACoT can be

for PRBCs transfusion is set to 7–9 g/dL [23] lower by the use of an antifibrinolytic agent. The
where in US guideline Hb is set to 7 g/dL [30]. CRASH-2 study [40] assessed the systematic
These recommendations are based on studies injection of tranexamic acid (TXA) in trauma
showing that PRBCs transfusions can be patients with or at risk of severe bleeding. The
­associated with increased mortality, lung injury, competitive binding of the plasminogen/plasmin
increased infection rate and renal failure in site on the fibrin allows the TXA to inhibit the
injured patients and mainly on the Transfusion fibrinolysis. The injection of a loading dose of 1 g
Requirements in Critical Care (TRICC) study of TXA over 10 min followed by the infusion of
demonstrating no efficacy of liberal approach 1 g over 8 h led to a significant reduction in mor-
(Hb threshold of 10–12 g/dL) versus restricted tality from bleeding without an increase in throm-
approach (7–9 g/dL) on mortality [31]. For boembolic events rate. From that same trial, a
patients with concomitant haemorrhagic shock deeper analysis showed that TXA lowers the risk
and traumatic brain injury, recent studies demon- of death by bleeding by 2.5% if given less than 1 h
strate no beneficial effect of a higher Hb thresh- after trauma and by 1.3% if given between 1 and
old for RBCs transfusion on mortality or 3 h after trauma. However, the risk is increased by
neurological outcomes but a higher risk of throm- 1.3% if the TXA is given more than 3 h after
boembolic events [32, 33], even if a higher Hb trauma [41]. The MATTERs study conducted in
improves local cerebral oxygenation [34]. military setting later consolidated these conclu-
RBCs play also a major role in haemostasis. sions [42]. Based on these results, the European
Circulating RBCs marginate the platelets close to guideline recommends the systematic injection of
the endothelium, enhancing their adhesion capa- TXA (1 g/10 min, 1 g/8 h) as soon as possible,
bilities [35], and support thrombin generation within the 3 h after the injury [23].
providing interactions with coagulation factors
on their cellular surfaces [36].
6.2.6 P
 lasma and Platelet
Transfusion in Haemostatic
6.2.5 Fibrinolysis Prevention Resuscitation

Fibrinolysis is a key component of the physio- Coagulation factors and platelets can be shed,
logical haemostasis system. It mainly involves consumed, diluted or inactivated in severe trauma
the tissue plasminogen activator (tPA) and its patients. Even if they play only a partial role in
inhibitors, the plasminogen activator inhibitors the ACoT, their replacement is crucial to restore
(PAI1 and 2) to regulate the activation of the the haemostasis. Standard available fresh frozen
plasminogen into plasmin, responsible for fibrin plasma (FFP) contains all the major coagulation
binding and degradation. However, a huge stim- factors in proportions close to the physiological
ulation of the coagulation system after severe levels and seems to have anti-inflammatory prop-
trauma and activated protein C (aPC) system erty while lessening the endothelial hyper-­
activation by tissue hypoperfusion [37] can lead permeability after haemorrhagic shock [43]. Its
to an exacerbation of the fibrinolysis. This hyper- transfusion should be initiated as soon as possible
fibrinolysis is an essential part of the acute coag- to avoid iatrogenic or physiological dilutional
ulopathy of trauma (ACoT) and is associated coagulopathy during a balanced resuscitation
with a mortality rate of nearly 90% [38]. with PRBCs. However, the optimal ratio of FFP
The best way to assess hyperfibrinolysis in to PRBCs remains of debate. Some studies
trauma patients is to use viscoelastic tests. showed a potential benefit of an FFP-PRBCs
However, the low sensitivity of this method does ratio close to 1:1 [44, 45]. However, these results
not allow to detect low increases in fibrinolytic were discussed and potentially flawed by survival
activity, still accountable for ACoT [39]. bias (i.e. less severe patients survive longer
6  Damage Control Resuscitation 63

enough to get more plasma, thawed plasma being tices because of some misconceptions (necessity
available later than PRBCs) [46]. The recent for whole blood to be ABO specific, impossibil-
PROPPR randomized clinical trial [47] compared ity to obtain leucoreduced whole blood while
1:1:1 FFP-PLT-PRBCs ratio to 1:1:2 in severe maintaining platelets and loss of platelet function
trauma patients without survival bias. caused by cold storage) [55].
Unfortunately, the results showed a
­nonstatistically significant reduction in mortality
for the 1:1:1 ratio group, letting the question 6.2.7 Viscoelastic Techniques
open. The European guideline proposes to trans- and Administration
fuse 1 FFP every two PRBCs during the initial of Concentrated Factors
management of patients with expected massive
haemorrhage, continued with goal-directed ther- Standard coagulation tests are of little use for
apy based on standard laboratory (PT or aPTT haemorrhagic shock management because they
inferior to 1.5 times the normal controls) and/or generally require more than an hour, and urgent
viscoelastic tests [23]. To resolve the delay in corrective action may not be delayed that long.
availability of the FFP, plasma can be stored as To adapt the treatment of haemostasis after the
thawed plasma or liquid (fresh nonfrozen) initial phase, viscoelastic techniques (VETs) may
plasma. But in this form, labile coagulation fac- be very useful. VETs have been developed for
tors like FVIII can be depleted [48]. Lyophilized several years and represent a comprehensive
plasma provided by the French military is a nice assessment of clot formation based on the mech-
option. Available in 10 min, stable at room tem- anisms originating coagulopathy, including, in a
perature and universal, it offers a great alternative second stage, inflammatory phenomena [56, 57].
to FFP [49]. It is possible to obtain a faster and more accurate
Fibrinogen, a key component in the coagula- evaluation of haemostasis through the use of acti-
tion cascade, is the first and most depleted factor vator or inhibitor which allows to distinguish
in haemorrhagic trauma patients [50]. However, phenomena occurring during ongoing bleeding
FFP concentration in fibrinogen is not high such as fibrinogen deficit and hyperfibrinolysis.
enough to restore fibrinogen levels with only FFP Identifying deficits makes possible to intervene
transfusion [51], and it may be required to admin- specifically with clotting factor concentrates,
istered fibrinogen through cryoprecipitate or avoiding the use of labile blood products (LBP),
fibrinogen concentrate. and, although this remains to be demonstrated
Platelet depletion or dysfunction [52] in formally, reduce morbidity related to the use of
trauma patients needs to be addressed by platelet the LBP (multiple organ failure, infection, ARDS,
transfusion. Platelets are available as platelet TRALI and TACO) [58–60]. According to the
concentrate (PLT) or apheresis platelets (aPLT) latest European guideline, VETs are accepted as
containing approximately six times more plate- alternative to standard coagulation tests to guide
lets and plasma. The European guideline [44] the treatment of posttraumatic coagulopathy
proposes to transfuse platelets if platelet count is (grade 1C) [23].
less than 50.109/L in trauma patients or less than
100.109/L in case of ongoing bleeding or trau- 6.2.7.1 Principles of Clot Viscoelastic
matic brain injury. Property Studies
The best way to replace shed whole blood Clot formation is assessed with ROTEM® (Tem
after or during haemorrhage would be to use GMBH, Munich, Germany) or with TEG®
whole blood, in replacement for component ther- (Haemoscope Corporation, Niles, Illinois, USA).
apy. Even if used and authorized in remote mili- These tools explore dynamics of clot develop-
tary setting when blood products are lacking and ment, stabilization and dissolution (fibrinolysis)
needs for transfusion surge [53, 54], this tech- [60–64]. The measured parameters are time (s),
nique has not reached the routine clinical prac- amplitude (mm) or angles. The measurements are
64 E.J. Voiglio et al.

made on whole blood collected in a citrated tube. (FIBTEM) and level of fibrinogen [67, 68].
The recalcified blood is then placed in a cuvette Similarly, TEG® R parameter (equivalent to CT)
heated to 37 °C (or to temperature of the patient), is correlated to PT; correlations were observed
in which a pin is plunged. The speed of rotation between the parameter R (equivalent to CT) and
thereof will depend on the viscosity of blood. PT [69, 70]. However, this good correlation
According to the technique, it is either the cuvette between standard and viscoelastic techniques at
which rotates (TEG®) or the pin (ROTEM®). In admission may vary during the management
the latest version of TEG®, measures are made [57]. Thus, a CT EXTEM is less correlated to PT
by an electro-optical technique. To accelerate the after attempt to correct coagulopathy and/or
technical and differentiating phenomena involved depending to pathophysiological criteria as aci-
in haemostasis disorders, activators are added. dosis and hypothermia [57]. The standard test
They depend on the type of techniques used [60]. that estimates the concentration of clotting fac-
ROTEM® analyser uses routinely four chan- tors does not take into account the effect of
nels: INTEM (intrinsic contact activation path- inflammation that develops in the hours follow-
way explored by adding ellagic acid), EXTEM ing the trauma and activates coagulation. Thus,
(extrinsic pathway explored by adding tissue fac- only VETs that take into account all parameters
tor), FIBTEM (addition of cytochalasin D which can provide a fair image of coagulation status
blocks the platelets to explore fibrinogen func- [57]. The possibility to predict the need for mas-
tion) and APTEM (addition of aprotinin for sive transfusion has been reported with ROTEM®
inhibiting and therefore exploring fibrinolysis). [68, 71, 72] as well as with TEG® (rapid-TEG)
Two other channels are used in specific circum- [73]. Many algorithms have been proposed to
stances: HEPTEM (INTEM + heparinase to treat bleeding disorders. However these algo-
assess heparin effect) and ECATEM (addition of rithms are specific to either technique and
ecarin to detect thrombin inhibitors). In trauma, non-interchangeable.
most useful channels are EXTEM and
FIBTEM. Thus, a deficit in prothrombin and in 6.2.7.3 VETs and Coagulation Factor
fibrinogen and a low platelet count can be dis- Concentrates
criminated. As an example, an EXTEM with a Post-traumatic coagulopathy is complex and
short clotting time (thrombin formation correct) includes phenomena of coagulation factor loss,
and with a diminished maximal clot firmness will dilution, thrombocytopenia, platelet disorders,
suggest low platelet activity if maximal clot firm- consumption and fibrinolysis [74]. Fibrinogen
ness is normal with FIBTEM. deficiency is the most observed among factor
TEG® analyser uses generally one single deficiencies. The massive release of tissue factor
channel after activation by kaolin (equivalent to which activates haemostasis and increases throm-
INTEM). However, it has been shown that plate- bin generation is important to consider. Thus, in
let and fibrinogen contributions to maximal trauma patients, thrombin generation remains
amplitude could not be differentiated [65]. increased as long as factor levels remain >30%
Therefore TEG® can now be performed with [75]. This increase in thrombin generation asso-
addition of both tissue factor and kaolin (rapid-­ ciated with the frequently observed fibrinogen
TEG) to explore the extrinsic pathway, and with deficiency suggests the order of administration of
addition of abciximab, a potent platelet inhibitor, haemostatic products. It is thus likely that fibrin-
to explore fibrinogen function [66]. ogen concentrates have to be administered first,
followed in a second phase (ideally according to
6.2.7.2 Coagulopathy Diagnosis by VETs standard coagulation tests or VETs) by the FFP
At admission, the results of the standard biology and the prothrombin complex concentrate (PCC)
are correlated to some ROTEM® parameters, except, of course, situations of severe haemor-
e.g. clotting time (CT) (EXTEM) and PT (pro- rhagic shock when fibrinogen FFP and PCC are
thrombin time) or maximal clot firmness (MCF) administered simultaneously. This method is
6  Damage Control Resuscitation 65

only valid when fibrinogen concentrates are Finally, in severe trauma, situations of hyper-
available (fibrinogen concentrates and/or fibrinolysis whose prognosis is catastrophic can
cryoprecipitate). be observed. TEG® and ROTEM® allow a rapid
ROTEM® was evaluated in trauma through and accurate diagnosis of hyperfibrinolyses [82]
retrospective or prospective observational stud- but will lack sensitivity to assess the intensity of
ies. The level of proof thus remains relatively fibrinolysis especially if minor or moderate [39].
low. Schöchl et al. suggested in a first study that Usually thresholds of 3% maximum fibrinolysis
ROTEM®-guided administration of coagulation (maximum lysis) on TEG® and 15% on
factors improved patient survival when compared ROTEM® are applied to diagnose hyperfibri-
to a predictive mortality score (TRISS) [76]. The nolysis. If in Europe, tranexamic acid is widely
same group showed that when comparing patients used since the CRASH-2 trial in severe trauma
treated with factor concentrates guided by [40], in North America, the practice is rather to
ROTEM® with patients receiving labile blood administer tranexamic acid to patients with
components (LBC) guided by the standard biol- hyperfibrinolysis documented by VETs [82].
ogy, they could reduce significantly the use of
LBC but also the incidence of multiple organ fail-
ure without affecting survival [77]. In a recent 6.3  amage Control Resuscitation
D
study, an Italian team confirmed the reduction of once Bleeding Has Been
the use of LBC reducing costs significantly by Stopped
more than 23% but still with no change in sur-
vival [78]. The issue with all these studies (how- Further resuscitation once haemostasis has been
ever this could also be considered an advantage) achieved is the intensive care unit resuscitative
is that ROTEM® use is combined with that of phase where physiological and biochemical sta-
factor concentrates making it difficult to know bilization is achieved and a thorough tertiary
what ultimately is most important [79]. A examination is performed to identify all injuries
European randomized study should start soon to (Fig. 6.3) [83]. This step is devoted to reverse the
compare standard biology and ROTEM® using sequelae of hypotension-related metabolic failure
LBP in the same initial ratio (iTACTIC Study, and support physiological and biochemical resto-
NCT02593877, trial.gouv). ration. Simultaneous treatment of all physiologi-
As regards TEG®, a retrospective study cal abnormalities is essential, and as a result, the
involving 1974 patients showed that TEG® first several hours in the ICU are extremely labour
could perfectly replace the standard biological intensive and often require the collaborative
tests [80]. In a recent randomized work, it has efforts of multiple critical care physicians, nurses
been shown that the use of TEG® in comparison and ancillary staff [84]. Efforts to warm during
with the standard biology could improve patient surgery, shorten the shock and improve coagula-
survival at 28 days without association with a tion are pursued. An aggressive approach to cor-
modification of LBP consumption in the first rection of coagulopathy is paramount, and
24 h except for cryoprecipitate (paradoxically procoagulant objectives remain the same.
greater in the group standard biology). A higher Assessment of visceral dysfunction is achieved
consumption of FFP and PCC was observed in (in particular the lung, kidney and liver).
the group standard biology in the early hours One of the keys to physiological restoration is
[81]. According to the authors, this result was the establishment of adequate oxygen delivery to
related primarily to a decreased mortality from body tissues. Haemodynamic optimization in this
bleeding and a decreased early mortality by ear- step of major post-shock inflammation often
lier diagnosis of coagulopathy and appropriate requires a significant fluid volume expansion due
action. A reduction of ICU stay length with an to vasodilation. The needs of vasopressors can
increased number of ventilator-free days was also be very consequent. Objectives of blood
also observed. pressure change and aim to restore adequate per-
66 E.J. Voiglio et al.

Damage control

Coagulation back to normal

Temperature to 37 °C
Compressive dressings, Tourniquet, Pelvic sling

Haemorrhage
Ambulance medical service

Intensive care unit

Operating room

HGB to 9 g/dl
control
Shock room

Fibrinogen + Factors II, VII, IX & X + Platelets

Paramedics

Orh- PRBS’s Type specific PRBC’s

Tranexamic acid
Permissive hypotension
Trauma
Combat hypothermia - rewarm
High flow oxygen

Fig. 6.3  Increasing power of damage control. Damage fibrinogen [23],coagulation factors [77] and platelet con-
control should be started in the field by the paramedics centrates [23]. The patient is transferred rapidly to the
who are trained to stop bleeding with local pressure or operating room (or angiography suite, as necessary).
tourniquets, administer oxygen and combat hypothermia. When bleeding has been arrested, blood pressure should
The race against the clock starts. The emergency team in return to normal. Damage control resuscitation should be
the field should strive for only minimal vascular filling, pursued until preset objectives of haemoglobin, tempera-
the objective being to obtain a systolic blood pressure of ture and coagulation parameters are attained. The com-
90 mmHg [23]; tranexamic acid should be administered parison with naval damage control can be made in that not
[42]. O-negative and then type-specific PRBC transfu- only should the water inflow be stopped, but the vital
sions are started with the objective of obtaining haemo- functions of the vessel must be restored as well (electric-
globin of 9 g/dL (according to European guideline [23]); ity, communications, propulsion, rudder) (E. Voiglio et al.
coagulation disorders are corrected by administration of J Visc Surg. 2016,153,13–24)

fusion of all organs (MAP = 65 mmHg). Invasive control operation is a marker of inadequate resus-
monitoring devices are generally used to guide citation or irreversible shock [84]. A complete
fluid administration and normalize haemodynam- physical examination or ‘tertiary survey’ of the
ics. Abramson and colleagues did show that serum patient should occur. This should include relevant
lactate clearance correlates well with patient sur- imaging studies where appropriate, and the patient
vival and that the ability to clear lactate to normal should also proceed to CT scan to detect occult
levels within 24 h was paramount to ensuing injuries if stable enough. In cases of blunt trauma,
patient survival [85]. Immediate and aggressive completion of the spinal survey is imperative.
core rewarming not only improves perfusion but Finally, the scheduled revision surgery is the last
also helps reverse coagulopathy. All of the warm- step of the DC strategy and occurs after 12–48 h
ing manoeuvres initiated in the trauma bay and (sometimes 72 h) of stabilization.
operating theatre should be duplicated in the The consensual approach is to consider the
intensive care unit. Gentilello showed that failure second look when lethal triad is under control. It
to correct a patient’s hypothermia after a damage has two objectives: the final repair organs (pack-
6  Damage Control Resuscitation 67

ings removal, intestinal anastomoses and defini- Hess JR. Damage control resuscitation: directly
addressing the early coagulopathy of trauma.
tive vascular repair) and the permanent closure of
J Trauma. 2007;62(2):307–10.
the abdomen. 2. Fries CA, Midwinter MJ. Trauma resuscitation and
One should keep in mind that if a patient does damage control surgery. Surgery (Oxford).
not normalize haemodynamically or lactic acid or 2010;28(11):563–7.
3. Heesch CM. Reflexes that control cardiovascular
base deficit fail to improve, the patient should be
function. Am J Phys. 1999;277:S234–43.
taken back to the operating theatre earlier for re- 4. Clemetson KJ. Platelets and primary haemostasis.
exploration. Generally, two subgroups of patients Thromb Res. 2012;129:220–4.
are seen in this step that require ‘unplanned’ re- 5. Chapin JC, Hajjar KA. Fibrinolysis and the control of
blood coagulation. Blood Rev. 2015;29(1):17–24
operation before physiological restoration. The
6. Hess JR, Brohi K, Dutton RP, et al. The coagulopathy
first is the group of patients who have ongoing of trauma: a review of mechanisms. J Trauma.
transfusion requirements or persistent acidosis 2008;65:748–54.
despite normalized clotting and core temperature. 7. Huckabee WE. Relationship of pyruvate and lactate
during anaerobic metabolism. I. Effects of infusion of
Monitoring of the clinical (blood pressure, tachy-
pyruvate or glucose and of hyperventilation. J Clin
cardia, suction drains, dressings) and biological Invest. 1958;37:244–54.
parameters (haemoglobin, lactate level) can lead 8. Martini WZ. Coagulopathy by hypothermia and aci-
to the decision to further surgery and/or angiogra- dosis: mechanisms of thrombin generation and fibrin-
ogen availability. J Trauma. 2009;67(1):202–8.
phy. These patients are usually found to have
discussion 208-9
ongoing surgical bleeding or a missed visceral 9. Moore EE. Thomas G. Orr Memorial Lecture. Staged
injury that was not treated adequately during the laparotomy for the hypothermia, acidosis, and coagu-
initial damage control operation and have a very lopathy syndrome. Am J Surg. 1996;172:405–10.
10. Churchill-Davidson HC. Some problems of massive
high mortality rate [86]. The second group requir-
blood transfusion. Proc R Soc Med. 1968;61:681–2.
ing unplanned return to the operating theatre have 11. Boffard KD, Choong PI, Kluger Y, et al. The treat-
developed abdominal compartment syndrome ment of bleeding is to stop the bleeding! Treatment of
defined as sustained or repeated intravesical pres- trauma-related hemorrhage. Transfusion.
2009;49:240S–7S.
sure above 20 mmHg in the presence of new single
12. Cabrales P, Tsai AG, Intaglietta M. Resuscitation

or multiple organ system failure [87]. This could from hemorrhagic shock with hydroxyethyl starch
be the consequence of abdominal trauma which is and coagulation changes. Shock. 2007;28:461–7.
accompanied by a visceral oedema and haemato- 13. Clarke JR, Trooskin SZ, Doshi PJ, et al. Time to lapa-
rotomy for intra-abdominal bleeding from trauma
mas but also the use of intra-abdominal packing.
does affect survival for delays up to 90 minutes.
J Trauma. 2002;52:420–5.
Conclusion 14. ATLS Subcommittee, American College of Surgeons’
The treatment of bleeding remains to stop the Committee on Trauma, International ATLS working
group. Advanced trauma life support (ATLS®): the
bleeding. DCR is together with DCS part of a
ninth edition. J Trauma Acute Care Surg. 2013;74:
global DC strategy. DCR is a potent tool to 1363–6.
hinder and even reverse the lethal triad. 15. Frerk C, Mitchell VS, McNarry AF, Mendonca C,
Delaying bleeding control under the pretext Bhagrath R, Patel A, O’Sullivan EP, Woodall NM,
Ahmad I, Difficult Airway Society intubation guide-
that DCR is available and effective is a falla-
lines working group. Difficult Airway Society 2015
cious conduct that results in increased mor- guidelines for management of unanticipated difficult
bidity and mortality. intubation in adults. Br J Anaesth. 2015;115(6):
827–48.
16. Butler FK, Dubose JJ, Otten EJ, Bennett DR, Gerhardt
RT, Kheirabadi BS, Gross KR, Cap AP, Littlejohn LF,
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 Head Injury
7
James M. Schuster and Philip F. Stahel

The management of a head-injured patient with threatening and neurologic injuries, but with a
multiple other injuries presents one of the most simultaneous evaluation and possible manage-
challenging and difficult clinical scenarios in ment of orthopedic, spine, and craniofacial inju-
trauma critical care. This is due in part to the ries. This often requires flexibility on the part of
fact that the treatment of other injuries, such as the involved services as surgical decisions should
orthopedic, spine, and craniofacial fractures, not be based on convenience. This approach pro-
has the potential for worsening the neurologic vides an opportunity for imaginative and innova-
outcome. This potential worsening is not neces- tive surgical management. Definitive repair
sarily directly related to the p­ rimary repair or procedures are not always possible or appropriate
the timing of surgery, but more to the fact that because of the length of the case, inability to
additional surgery with potential blood loss and appropriately provide neurologic monitoring,
possible resultant hypotension or hypoxia can and the potential for significant blood loss and
adversely affect an injured brain. It has been massive fluid administration. Other options
shown that a single episode of hypotension or include placement of external fixation, choosing
hypoxia can adversely affect outcome of all a surgical approach based on reduced operative
severities of head injury [1–6]. time and reduced blood loss, or staged
Management of polytrauma patients with procedures.
head injuries requires strict adherence to ACLS The trauma surgery team often serves as the
principles, close coordination, and communica- coordinator of care for multiple injured patients,
tion between all involved surgical specialties, as each involved service can be somewhat myo-
including simultaneous procedures when appro- pic in their approach to the patient. However,
priate. Decision making is all about assessing once the life-threatening hemodynamic injuries
relative risk with priority initially given to life-­ are stabilized, the neurosurgery consultant feels
the obligation to protect the brain and spinal cord
J.M. Schuster, MD, PhD at all costs. While the neurosurgeons are usually
Department of Neurosurgery, University of very involved with the simultaneous manage-
Pennsylvania, Philadelphia, PA, USA ment of spine injuries, they also have to be well
P.F. Stahel, MD (*) informed about the effects of delayed treatment
Department of Orthopaedics and Department of of orthopedic or craniofacial injuries. Again, this
Neurosurgery, University of Colorado School of
very often comes down to an assessment of rela-
Medicine, Denver Health Medical Center, Denver,
Colorado, USA tive risk. This is because ultimately, while
e-mail: philip.stahel@dhha.org patients with lost or suboptimally functioning

© Springer International Publishing AG 2017 71

H.-C. Pape et al. (eds.), Damage Control Management in the Polytrauma Patient,
DOI 10.1007/978-3-319-52429-0_7
72 J.M. Schuster and P.F. Stahel

Polytrauma patient with head injury

ACLS
Head CT
Neuro exam

Operative head injury (emergent)

Craniotomy/
craniectomy Yes No

Other operative injuries Other operative injuries

Yes
No No

Simultaneous/sequential
procedures if possible (Consider timing)
Yes

ICU

Spine
Facial
fractures
Spine
Early Facial
Pelvis/ stabilization fracture
Long bone With least
Time and
Blood loss
Thoracolumbar
Cervical Repair CSF leak
at craniotomy Ortho Delayed
Delay primary repair Repair
Unless
CSFleak
Reduction/ Ext-fix
Ext-fix
stabilization washout
washout

Decompression/
stabilization

Fig. 7.1  Decision-making flow sheet for polytrauma patient with associated head injury

limbs or craniofacial defects can return to head injuries in polytrauma patients including an
­independent functioning, this is less often the initial assessment paradigm (Fig. 7.1) to aid in
case in patients with significant brain injuries. making decisions about the need for emergent
Again an overall concern for avoiding secondary neurosurgical intervention, as well as a system
injury must be paramount. The intent of this chap- for prioritizing and coordinating the treatment of
ter is to provide a template for rapidly ­managing other injuries.
7  Head Injury 73

7.1 Initial Assessment may be awake and talking (Fig. 7.2). Because of
basal-frontal swelling near the brainstem, any
The overall approach to a head-injured patient perturbation such as a seizure or hypoxemia can
should be aggressive and timely treatment of the set in motion a rapidly progressive clinical spiral
primary injury and avoidance of secondary leading to fixed dilated pupils which then requires
injury. The basic underlying questions that need emergent surgery to avoid poor outcome [9].
to be addressed early in the assessment are as fol- Once the decision is made that a patient needs
lows: “Does this problem need immediate surgi- an operation, the question then arises: What oper-
cal intervention? Is the injury likely to require ation? The operative plan must take into account
intervention in the near future? Or is this an the presence of intracranial hematomas, overall
injury unlikely to need surgical intervention?” brain swelling, intracranial foreign bodies,
This decision is based on a clinical and radio- involvement of major vascular structures, and the
graphic assessment of the patient. Injuries such involvement of air sinuses that need to be
as epidural hematomas (EDH), subdural hemato- addressed to avoid CSF leak. The general
mas (SDH), intraparenchymal hemorrhages, approach is to evacuate hematomas, debride
­contusions, or penetrating injuries with altered devitalized tissue, remove accessible foreign
neurologic status (especially pupillary abnormal- bodies, and repair CSF leaks. The other decision
ities and lateralizing motor finding) often require is whether the patient is likely to have significant
emergent surgical intervention. The question of problems with raised intracranial pressure
salvageability often arises especially in patients ­postoperatively. Concerns for postoperative man-
with fixed, dilated pupils and Glasgow Coma agement often lead the decision to perform a cra-
Score of 3 [7, 8]. While the decision should be niectomy with storage of the bone subcutaneously
individualized, the survivability of such injuries in the abdomen or in the freezer until which time
is debatable. However, it is imperative that the the brain swelling has subsided and the bone can
clinical assessment is not altered by pharmaco- be replaced. This procedure also requires dural
logic muscle paralysis and/or injuries/medica- augmentation with pericranium, or a dural substi-
tions that can alter pupillary function. There is tute to allow swelling of the brain out of the bone
also a danger of being too reassured by a patient’s defect, thus decompressing the brain. The proce-
initial clinical assessment such as in patients with dure can be performed unilaterally, bifrontally, or
the “talk and die syndrome.” This is generally bihemispheric depending on the pattern of injury
seen in a young patient with bifrontal and/or sub- [10–14] (Fig. 7.2b,c). The removal of bone must
frontal injuries (often contusions) who initially be adequate to ensure that as the brain swells out

Fig. 7.2  Patient at risk for “talk and die syndrome.” (a) logic decline. (c) CT showing replacement of bone at
CT scan showing frontal contusions. (b) CT scan showing 8 weeks after patient made excellent neurologic recovery
right hemicraniectomy (arrow) after progressive neuro-
74 J.M. Schuster and P.F. Stahel

of the defect, it is not lacerated or contused ICU with the same vigilance with regard to moni-
against a bone edge. Craniectomy, if performed toring and proactive intervention [25].
adequately, is the most effective and durable way As can be seen from the above discussion,
to reduce intracranial pressure. While ultimate there is an apparent paradox in the treatment
outcome is still heavily tied to the severity of the approach to a patient with a head injury and other
initial injury and neurologic status, there is evi- associated injuries. We aggressively and defini-
dence that hemicraniectomy can reduce intracra- tively treat the primary CNS injury to help avoid
nial pressure and improve brain oxygenation as secondary injury while treating other associated
measured by invasive monitoring in head-injured injuries in a damage control fashion. This is due
patients [15, 16]. The other advantage of hemi- in part to the fragile nature of CNS structures
craniectomy and the subsequent improvement in with little reparative capability, little function
ICP and brain oxygenation is it often makes post- reserve, and a narrow timing window with regard
operative management less physiologically to salvageability after injury. We will discuss this
stressful to the patients as they are less likely to approach in the subsequent sections. Finally, by
require osmotic diuretics, blood pressure support, definition, surgical decision making involves rel-
and heavy sedation. In patients with less severe ative risk assessment, and therefore it is impera-
injuries but labile intracranial pressure, the place- tive that patients and families understand the
ment of a ventriculostomy for CSF diversion can complexity of these interactions and have realis-
be an extremely effective and less physiologi- tic expectations for outcome and recovery.
cally stressful way of treating raised intracranial
pressure.
After aggressive surgical treatment of the pri- 7.2  ead Injury Associated
H
mary intracranial injury, the introduction of with Major Chest/Abdominal
aggressive neurocritical care has been shown to Injury
positively impact brain-injured patients [17–19].
Using monitoring to measure brain oxygenation Stabilizing a patient’s cardiopulmonary status
and intracranial pressure, the use of continuous must always be the highest priority in dealing
EEG to detect seizures and ischemia, and with a trauma patient. However, there are clinical
protocol-­driven approaches to glycemic control scenarios in which a patient is taken emergently
and hyperthermia are now routinely imple- to the operating room to deal with life-­threatening
mented [20–22]. Early tracheostomy and enteral thoracoabdominal trauma with a suspected brain
access are now initiated to facilitate patient care injury and no confirmatory neuroimaging. There
[23, 24]. is traditional support for placing burr holes on the
Finally, consulting services such as orthope- side of a “blown” pupil in the ED or in the OR
dics often enquire about when a patient is stable during thoracoabdominal surgery. While if per-
enough to allow further surgery. This decision formed correctly there is the potential to relieve
needs to be individualized for each patient based pressure from an evolving EDH or SDH, this
on injury severity, clinical exam, neurophysio- may not be the definitive procedure and a crani-
logic stability based on monitoring, the perceived otomy may also be required [26, 27]. This in
urgency of the proposed surgery, and the poten- theory could follow after cardiopulmonary stabi-
tial physiologic stress of the surgery including lization. In the case of bilateral “blown” pupils,
length, risk of large blood loss, or large fluid vol- practitioners must keep in mind that hypoxia/
ume administration. Physiologic monitoring is hypotension can cause pupillary abnormalities
also recommended during the case (ICP, brain that do not indicate an intracranial space-­
oxygenation) which may affect positioning and occupying mass [28]. As neurosurgeons, we are
the potential of aborting the procedure if a prob- sometimes asked to place intracranial monitors in
lem arises. Essentially, management in the OR patients undergoing “crash” thoracotomies or
must be an extension of the management in the exploratory laparotomies with suspected
7  Head Injury 75

i­ntracranial pathology. However, elevated ICP is injury type including mild intimal irregularities,
difficult to interpret in a patient lying flat or head intimal flaps, pseudoaneurysms, fistulas, and
down and receiving massive fluid resuscitation. occlusions. The need for treatment is determined
Additionally, therapeutic interventions such as in part by the collateral circulation to the brain
mannitol would not be indicated in a hypotensive and the degree to which the lesion is thrombo-
patient. The key is early cranial imaging. A rapid genic [35]. It is beyond the scope of this chapter
helical CT scan preoperatively if possible, or uti- to discuss the management of traumatic carotid
lization of portable CT scanners interoperatively, injury, but the risk of anticoagulation would have
would obviate this problem. to be considered in a patient with significant
intracranial injury [36].

7.3  ead Injury Associated

H
with Cranial Facial Injury 7.4  ead Injury with Spine
H
Injury
Head injuries from blunt force trauma or pene-
trating injuries have the potential for involvement There is a high incidence of associated spine
of the air sinuses such as the frontal sinus as well fracture with head injury especially with falls and
as cranial facial structures [29, 30]. While not motor vehicle accidents [37]. It is often difficult
absolute indications for surgical intervention, the to clinically clear the cervical spine in a patient
presence of pneumocephalus and/or a CSF leak with a significant head injury even without obvi-
must be closely monitored. Increasing pneumo- ous radiographic abnormalities. But the more
cephalus or rhinorrhea/otorrhea that does not pressing difficulty occurs with the combination
resolve spontaneously may require surgical inter- of an operative head injury and an operative spine
vention. The goal of surgery in a patient with sig- injury. In the case of spine fracture/dislocation
nificant intracranial pathology (hematoma, with a spinal cord injury such as with bilateral
contusion) associated with pneumocephalus/CSF jumped facets and burst fractures, early decom-
leak (for instance, from an anterior skull base pression and stabilization is optimal [38, 39].
fracture/frontal sinus fracture) is to adequately While these injuries can be decompressed in trac-
deal with the intracranial pathology and stop the tion, this delays mobilization which has been
CSF leak: essentially isolating the brain from the shown to negatively impact outcome secondary
nose [31, 32]. There is often input from multiple to pulmonary issues [40–43]. With simultaneous
services including neurosurgery and ENT, operative injuries, the cranial portion could be
OMFS, or plastics, but it is generally in the completed, and the cervical spine reduced and
patient’s better interest to delay the definitive stabilized through an anterior approach if possi-
repair of facial fractures because of the overall ble. In critically ill patients with unstable thora-
extension of the operative time [33]. If CSF columbar fractures, a posterior approach can be
diversion is required to protect the repair, a ven- utilized in a time-efficient and less physiologi-
triculostomy is preferred to a lumbar drain in a cally stressful manner for decompression/stabili-
patient with suspected intracranial swelling. zation even if an anterior approach will
Compression of the optic nerve could also be subsequently be required. This staged stabiliza-
addressed by this approach if indicated [34]. tion/decompression allows mobilization and thus
Skull base fractures can also cause damage to helps avoid life-threatening pulmonary compli-
carotid arteries. There should be a high index of cations [42, 43]. These stabilization procedures
suspicion with these types of fractures. Treatment can sometimes be performed in a p­ ercutaneous/
options include medical management, or more minimally invasive method, significantly reduc-
invasive surgical or endovascular therapy. ing blood loss [44].
Therapy depends on the risk-benefit ratio of each Blunt vertebral artery injury is associated with
option considering the natural history of each complex cervical spine fractures involving sub-
76 J.M. Schuster and P.F. Stahel

luxation, extension into the foramen transversar- to go to the OR for a less time-consuming and
ium, or upper C1 to C3 fractures [45]. The less physiologically stressful procedure. While
posterior circulation stroke rate has been reported this is an area of discussion, there is growing evi-
as high as 12–24% after traumatic vertebral artery dence to support this approach [51–53, 56].
injury [46, 47]. Treatment of vertebral artery inju-
ries such as dissections, pseudoaneurysms, fistu-
las, and occlusions must be individualized with 7.6 Summary
regard to the use of anticoagulation and/or endo-
vascular treatment based on the patients’ clinical The management of a polytrauma patient with a
status, risk of ischemic/thrombotic potential for significant head injury represents one of the most
the individual lesions, and the suitability of the complicated clinical scenarios encountered by the
patient for anticoagulation based on their intracra- trauma team. However, it provides an opportunity
nial pathology and other injuries [46–48]. to implement innovative and imaginative man-
agement strategies that require communication,
coordination, and flexibility among the involved
7.5  ead Injury with Orthopedic
H subspecialties. Primary intracranial pathologies
Injury need to be treated aggressively and secondary
injuries avoided at all costs. Head injuries, spine
The combination of head injuries and significant injuries, orthopedic injuries, and craniofacial
orthopedic injuries are relatively common with injuries with CSF leaks need to be assessed and
motor vehicle accidents and falls. Major orthope- treated simultaneously if possible. The definitive
dic trauma can be both life threatening (pelvic treatment of the noncranial injuries can often be
fractures with vascular injuries) and limb threat- delayed with the initial therapies designed to sta-
ening especially with open and potentially con- bilize spine, pelvis, and long bone injuries as well
taminated extremity injuries. Ideally, head as repairing CSF leaks associated with cranial
injuries and orthopedic injuries can be assessed facial injuries. This facilitates management in the
and if possible treated simultaneously. If the ICU and helps prevent pulmonary complications,
patient is going to the OR for an operative head which are a major source of morbidity and mor-
injury, every effort should be made to treat ortho- tality. Additionally, neurocritical care, provided in
pedic injuries in a damage control fashion. Any the ICU, needs to be extended to the OR to avoid
open fracture or other critical musculoskeletal secondary brain injury. Subsequently, with stabi-
injury that can realistically be splinted or casted lization and improvement of the head injury, the
and treated definitively in a delayed fashion noncranial injuries can be readdressed.
should be. Any injury that can be treated with
external fixation or washed out and closed when
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7  Head Injury 77

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 Chest Trauma: Classification
and Influence on the General
8
Management

Frank Hildebrand, Hagen Andruszkow,
and Hans-Christoph Pape

8.1 Introduction tion to the significant clinical implications in the

acute posttraumatic phase, severe chest trauma also
Most thoracic injuries are caused by blunt trauma, has a major impact on the later clinical course. In
whereas penetrating injuries only account for this context, a significant increase in ventilation
around 10% of these cases. Isolated blunt chest time and prolonged intensive care treatment has
trauma usually occurs after a minor traumatic been observed [6]. Furthermore, chest trauma has
impact and is characterized by mild injuries (e.g., been shown to result in higher incidences of acute
thoracic bruises, rib fractures) that can be treated respiratory distress syndrome (ARDS), systemic
conservatively in the vast majority of cases. In inflammatory response syndrome (SIRS), multiple
young adults with isolated chest trauma, a mor- organ dysfunction syndrome (MODS), and infec-
tality rate of 0–5% is described, whereas an tious complications (pneumonia) compared to
increase to 10–15% is found in the elderly popu- severely injured patients without severe chest
lation [1–3]. In geriatric patients aged ≥85 years, trauma [3, 7–9]. Accordingly, thoracic injuries
initial blood pressure <90 mmHg and specific have been associated with increased posttraumatic
injuries (hemothorax, pneumothorax, serial rib mortality. Particularly in patients with combined
fracture, pulmonary contusion) have been identi- chest trauma and severe traumatic brain injury
fied as risk factors for posttraumatic complica- (TBI), mortality rates of more than 70% have been
tions and adverse outcome [4]. described [1–3, 7, 10, 11]. Furthermore, 50–75%
In 80–90% of cases, severe chest trauma is asso- of deceased polytraumatized patients had a tho-
ciated with concomitant injuries [5]. Therefore, racic injury. This chest trauma-related increase in
thoracic injuries represent one of the most common posttraumatic complications might partly be
diagnoses in severely injured patients [6]. In addi- explained by an enhanced inflammatory response
that has especially been described after pulmonary
F. Hildebrand, MD • H. Andruszkow, MD (*) contusions [1–3, 7, 10–12].
Department for Trauma and Reconstructive Surgery,
University Hospital Aachen, Pauwelsstraße 30,
52074 Aachen, Germany
e-mail: fhildebrand@ukaachen.de;
8.2 Injuries After Chest Trauma
handruszkow@ukaachen.de
H.-C. Pape, MD, FACS
Thoracic injuries can affect the chest wall and the
Professor and Chairman, Department of Trauma, intrathoracic organs, including the pleura, dia-
Zurich University, Raemistr. 100, phragm, lungs, mediastinum, and the great blood
8091 Zurich, Switzerland vessels.
e-mail: papehc@aol.com

© Springer International Publishing AG 2017 79

H.-C. Pape et al. (eds.), Damage Control Management in the Polytrauma Patient,
DOI 10.1007/978-3-319-52429-0_8
80 F. Hildebrand et al.

8.2.1 Chest Wall Injuries during expiration). Posterior flail segments are
stabilized by overlying muscles as well as the
Rib fractures account for the majority of thoracic scapula and therefore may not cause severe
injuries and are found in around 50% of patients complications. In contrast, anterior and lateral
with blunt chest trauma. Rib fractures can result flail segments are mobile and can seriously
in pleural or pulmonary lacerations with devel- impair respiratory function. Additionally, a
opment of pulmonary hematoma, hemothorax, flail chest is frequently associated with lung
and pneumothorax. Typically, ribs IV–X are contusions [12].
affected. In the case of fractures of the first two Sternal fractures are seen in about 5% of
ribs, a particularly severe traumatic impact has patients with chest trauma [16]. Most fractures
to be assumed. As these two ribs are anatomi- involve the upper- or mid-part of the sternum.
cally close to vital structures, lesions of the bra- Sternal fractures are frequently accompanied by
chial plexus and different vessels (e.g., pulmonary and myocardial injuries, as well as
subclavian artery and vein) may occur. fractures of the thoracic spine.
Furthermore, lung contusions are likely. Sternoclavicular dislocations may occur
Fractures of the lower ribs are mainly caused by either in the anterior or posterior direction.
a direct local impact and can be associated with Posterior dislocations are more severe, as they
injuries to abdominal organs, such as the liver, can result in injuries of mediastinal blood ves-
spleen, and kidneys. sels, as well as in tracheal or esophageal damage
In the younger trauma population, rib frac- [17]. In general, the more common anterior dislo-
tures are usually caused by a severe traumatic cations can be treated conservatively, whereas
impact and are frequently associated with pulmo- posterior dislocations usually require closed or
nary contusions. In elderly patients, however, surgical reduction.
minor trauma also regularly results in rib frac- Due to the close anatomical relationship, chest
tures due to decreased bone elasticity and osteo- trauma is frequently accompanied by clavicular
porosis. In these patients, the fracture-related fractures. In particular, a high coincidence of cla-
pain often results in a reduction of breathing vicular fractures and specific thoracic injuries
depth with subsequent fluid retention and associ- (hemothorax, pneumothorax, lung contusions)
ated pulmonary complications, such as pneumo- has been described. Furthermore, fractures of the
nia and atelectasis. In older patients, each clavicula have been associated with injuries to
additional rib fracture increases the probability of the upper extremities and the cervical spine, as
death by 19% and the incidence of pneumonia by well as a higher overall injury severity in
27% [13, 14]. multiple-­trauma patients. Therefore, clinical and
In cases of serial rib fractures, at least three radiologic diagnostics are recommended to spe-
ribs of one or both thorax cavities are concerned. cifically focus on these body regions in the case
In addition to the risks of single rib fractures, of a clavicular fracture [18, 19].
increasing numbers of fractured ribs are associ- With a prevalence of approximately 4%,
ated with a reduced stability of the chest wall, fractures of the scapula are quite uncommon in
which might lead to a flail chest. severely injured patients [20]. Similar to cla-
A flail chest is found in about 15% of patients vicular fractures, scapular lesions are fre-
with blunt chest trauma [15]. It is defined as at quently associated with other injuries, such as
least two fractures per rib in at least two ribs. pneumothorax, hemothorax, and pulmonary
This results in a segment of the chest wall that and spinal injuries [21]. Most fractures affect
is separated from the rest of the thoracic cage. the body and neck of the scapula and can be
A separated segment of the chest wall is not treated conservatively. In contrast, displaced
able to contribute to lung expansion and is intra-articular glenoid fractures and displaced
associated with paradoxical breathing (inward juxta-articular fractures require a surgical
motion during inspiration and outward motion ­intervention [21, 22].
8  Chest Trauma: Classification and Influence on the General Management 81

8.2.2 I njuries of the Intrathoracic 8.2.2.2 Diaphragm Injuries

Organs A diaphragmatic rupture can be caused by blunt
or penetrating injuries. It occurs in 0.2–5% of
8.2.2.1 Pleural Injuries patients with blunt chest trauma [26, 27].
A pneumothorax occurs in 15–40% of patients Ruptures on the left side are three to four times
with chest trauma [23–25] and is defined as a col- more common than lesions on the right side. In
lection of air in the chest or pleural space that 5–10% of cases with diaphragmatic injuries, a
might result in a partial or entire collapse of the bilateral rupture is found [12]. A high proportion
lung. Leading symptoms are a unilateral breath of diaphragmatic ruptures are primarily not diag-
sound and tissue emphysema, which might either nosed [12], and the mortality of missed dia-
be caused by pleural laceration due to fractured phragm ruptures has been reported to be as high
ribs (closed pneumothorax) after blunt trauma or as 30% [28].
by penetrating injuries (open pneumothorax)
[16]. Lesions of the tracheobronchial tree might 8.2.2.3 Lung Injuries
also result in a pneumothorax. The most frequent Parenchymal lung injuries appear as pulmonary
complication of a pneumothorax is the develop- contusions and lacerations. Pulmonary contu-
ment of a tension pneumothorax. sions are one of the most frequent injuries in tho-
In cases of a pneumothorax in which air racic trauma patients [12]. Pulmonary contusions
enters the thoracic cavity and is captured during are either caused by direct trauma to the lung
the process of exhalation, a tension pneumotho- parenchyma or by indirect mechanisms, such as
rax can develop. This results in a collapse of the deceleration and shear forces. Lesions usually
ipsilateral lung with subsequent compression of occur in peripheral lung sections that are adja-
the mediastinum and the contralateral lung. A cent to bony structures [28]. Pulmonary contu-
suspected tension pneumothorax (distension of sions regularly appear 3–6 h after trauma and
jugular veins, unilateral breath sound, tissue generally resolve within 5–7 days [28, 29].
emphysema) has to be decompressed immedi- Histopathologically, these injuries are character-
ately by needle thoracostomy or a chest tube. A ized by an extravasation of blood and edema into
hemothorax is found in about 20–40% of patients the interstitial and alveolar space. Especially in
with blunt thoracic trauma. It results from vascu- younger patients, pulmonary contusions can also
lar lesions after blunt or penetrating trauma. In be found without accompanying osseous lesions
this context, a hemothorax can be caused by [12, 16, 30, 31]. However, serial rib fractures
diverse bleeding sources, such as intercostal and a flail chest are commonly associated with
arteries, internal mammary arteries, lung paren- pulmonary contusions [32]. Pulmonary lacera-
chyma, and the heart, as well as hilar and great tions are characterized by a disruption of the
vessels. The therapy of a hemothorax is the parenchymal architecture. With the exception of
placement of a chest tube. An undrained hemo- stab wounds, lung lacerations are always accom-
thorax can lead to a tension hemothorax with panied by pulmonary contusions [33]. Pulmonary
ipsilateral lung compression and subsequent dis- contusions and lacerations can be complicated
placement of the mediastinum [16]. A chronic by the development of ARDS, which is the con-
hemothorax can be complicated by pleural sequence of a systemic inflammatory response
empyema or a fibrothorax that might result in a after chest or general trauma.
restrictive pulmonary disease [12]. A lesion of Pathophysiologically, ARDS is caused by the
the thoracic duct can result in the development damage of the alveolar-­capillary barrier by acti-
of a chylothorax. A rupture of the upper part of vated neutrophils resulting in an extravasation of
the thoracic duct is associated with a left-sided fluid into the alveolar space [34, 35]. This sys-
chylothorax. Crossing the midline lesions of the temic inflammatory response can also affect pri-
lower parts of the thoracic duct results in a right- marily uninjured pulmonary sections [31, 36].
sided chylothorax. Radiographically, ARDS manifests as a diffuse
82 F. Hildebrand et al.

bilateral pulmonary infiltration [29]. Diverse the atrium or right ventricle may not cause notice-
trauma-related predictive models have been sug- able symptoms. The majority of pericardial tam-
gested for early prediction of ARDS [37–39]. In ponades occur after penetrating trauma, but also
this context, age, Acute Physiology and Chronic appear in about 1% of blunt chest trauma patients
Health Evaluation (APACHE) II Score, injury [12, 16]. Immediate pericardiocentesis is indi-
severity, blunt trauma mechanism, pulmonary cated for restoration of normal cardiovascular
contusion, massive transfusion, and flail chest function [42, 43].
have been associated with an increased risk of Cardiac injuries are observed in 15–25% of
ARDS [37]. patients with chest trauma [44]. The incidence
increases to 75% in cases of sternal fractures,
8.2.2.4 Injuries to the Mediastinum parasternal rib fractures, and ruptures of the dia-
A pneumomediastinum (mediastinal emphy- phragm [45]. Myocardial contusions occur due to
sema) may occur after pharyngeal, tracheobron- the rupture of the intramyocardial vessels and can
chial, or esophageal lesions after either result in structural injuries and functional
penetrating or blunt trauma. Besides chest radi- changes. Structural injuries include the perfora-
ography, diagnostics should include esophageal tion of cardiac muscles or the ventricular septum,
and tracheobronchial endoscopy. A mediastinal as well as disruption of the papillary muscles and
hematoma results from vascular injuries and valves [12]. Furthermore, arrhythmias may arise
might result in an enlargement of the mediasti- as a functional complication following myocar-
num. Mediastinal widening is diagnosed in cases dial contusion. Cardiac aneurysms are focal
with a diameter of >8 cm and a mediastinum-to-­ evaginations of the septal or ventricular walls.
chest ratio of >0.25. Tracheobronchial injuries True aneurysms frequently appear in the left ven-
occur in 0.2–8% of patients with blunt chest tricular anterior wall or at the apex after severe
trauma and are frequently accompanied by pul- blunt trauma. Cardiac pseudoaneurysms typi-
monary or vascular injuries [40, 41]. Tracheal cally occur after penetrating trauma and are usu-
lesions usually appear as transverse tears ally located in the left ventricular posterolateral
between the cartilaginous tracheal rings or longi- wall. Cardiac ruptures frequently affect the right
tudinal tears in the posterior tracheal membrane. ventricle due to its thin wall and the anatomical
Tracheal injuries require surgical repair to ensure position in the thoracic cavity. Severe torsion
airway continuity. Esophageal injuries after forces can also cause a cardiac avulsion with sep-
blunt chest trauma are rare. The majority of aration of the heart from the great vessels.
esophageal lesions are located in the cervical Traumatic aortic injuries include a spectrum
and upper thoracic sections. Depending on their of lesions due to severe deceleration trauma and
location, esophageal injuries can result in right- most frequently affect the aortic isthmus, fol-
or left-­sided pleural effusion. In order to avoid lowed by the aortic root and the diaphragmatic
subsequent complications, such as edema and aorta. Traumatic aortic ruptures occur in 2% of
infection (mediastinitis), surgical repair is patients with blunt chest trauma. In approxi-
required. mately 90% of cases, complete aortic ruptures
Pericardial injuries (e.g., organ and vascular are fatal at the scene of the accident. They can
ruptures) can result in air entrapment (pneumo- only be survived in cases of pseudoaneurysm
pericardium) or hemorrhagic influx (hemoperi- formation with containment of active bleeding
cardium) into the pericardial cavity. A by the aortic adventitia, a thrombus, or mediasti-
hemopericardium may be complicated by the nal structures. Traumatic aortic dissections are
development of pericardial tamponade with characterized by intimomedial tears. Type B
increased pericardial pressure and subsequent (descending aorta) dissections can be treated
hemodynamic instability. In particular, lesions of conservatively, whereas Type A (ascending
the intrapericardial aorta and left cardiac ventri- aorta) dissections require surgical repair due to
cle endanger the patients, whereas bleeding of the risk of pericardial bleeding, coronary artery
8  Chest Trauma: Classification and Influence on the General Management 83

laceration, and aortic valve rupture. Traumatic 8.3.1 Plain Chest X-Ray
aortic aneurysms are focal dilatations that
include the entire aortic wall, and these aneu- Plain chest X-ray is a frequently used diagnostic
rysms are at risk of rupture. Open surgery should tool to detect thoracic injuries [46]. In the clini-
be performed in aneurysms of the ascending cal routine, chest X-rays are performed in the
aorta that are symptomatic, rapidly expanding, anterior-­posterior (ap) and lateral directions of
or greater than 5.0–5.5 cm in diameter. In aneu- the upright sitting patient in full inspiration.
rysms of the descending aorta exceeding 6.0 cm, However, in multiple-trauma patients, plain
repair by endovascular stent grafting is chest radiography has to be obtained in the
recommended. supine position and, therefore, only in the ap
Injuries of the great intrathoracic vessels are direction. As a lateral view is not possible under
only found in 1% of blunt chest trauma patients these circumstances, the superimposition of dif-
[12, 16], but in more than 90% of patients with ferent structures and organs in the ap plane
penetrating trauma. After blunt trauma, injuries exacerbates the interpretation, thereby limiting
are mainly caused by deceleration mechanisms the diagnostic value [47]. In this context, the
and predominantly affect aortic branch vessels incidence of missed pneumothoraces (occult
and the superior or inferior vena cava, as well as pneumothoraces) on plain chest X-ray is thought
pulmonary veins. to be 2–15% [48–51]. Additionally, pulmonary
contusions are frequently either missed or
underestimated by chest radiography, especially
8.2.3 The Deadly Dozen in the early posttraumatic phase at admission
[52–57].
Among the aforementioned thoracic injuries, 12
typical life-threatening injuries have been identi-
fied that have been called the “deadly dozen.” 8.3.2 Computed Tomography
These 12 injuries are divided into the lethal six
and the hidden six. The lethal six (acute airway The deficits of plain chest X-ray for the diagnosis
obstruction, tension pneumothorax, pericardial of thoracic injuries can be compensated by a
tamponade, open pneumothorax, massive hemo- computed tomography (CT) scan, which repre-
thorax, flail chest) are immediately life-­ sents the most important examination method in
threatening injuries and have to be identified, and chest trauma patients [47]. A thoracic CT scan is
treatment has to be initiated during the primary superior to conventional chest radiography for
survey. The hidden six (aortic rupture, myocar- the assessment of pneumo- and hemothorax, pul-
dial contusion, tracheobronchial injuries, dia- monary parenchymal lesions, and bony injuries
phragmatic rupture, esophageal rupture, [23, 56, 58]. However, there is an ongoing discus-
pulmonary contusion) represent injuries that are sion about whether this additional information
easily missed. They have to be identified, and changes the treatment strategy [59, 60]. Marts
treatment has to be initiated during the secondary et al. reported a change in clinical management in
phase. only 6.5% of patients with chest trauma [56]. In
another study, CT has been credited with chang-
ing the treatment in up to 20% of chest trauma
8.3 Diagnostics patients [61]. Further studies found therapeutic
changes in 30–70% of the cases due to a
The correct diagnosis of thoracic injuries, as well CT-related amendment of diagnostic information
as prompt assessment of the severity of chest [62–64]. In general, a chest CT scan (pro re nata
trauma, is crucial for the further clinical course as part of a whole body CT) is recommended in
and outcome. Different diagnostic tools are avail- all trauma patients with multiple injuries, sus-
able in clinical routine. pected chest trauma, abnormal findings in the
84 F. Hildebrand et al.

i­nitial chest X-ray, and in cases of respiratory 8.4 Classification

insufficiency [64–68].
The evaluation of injury severity and the predic-
tion of outcome are important functions of scor-
8.3.3 Thoracic Ultrasonography ing systems. Early assessment of severe chest
trauma is decisive for the clinical course of
Ultrasound examinations represent a noninvasive multiple-­trauma patients, such as timing and kind
diagnostic tool that offers several advantages, of surgical interventions (early total care vs. dam-
including general availability, low procedural age control), and early and adequate therapy of
time/effort, and the possibility of repeated exami- the chest trauma itself is crucial to avoid post-
nations [69, 70]. With a sensitivity of 81% for the traumatic complications [1, 3, 12].
detection of intrathoracic fluid [71], ultrasonogra- Several scoring systems for the classification of
phy represents a reliable tool for diagnosis of blunt chest trauma have been developed. Most of
hemothorax [72]. Furthermore, with a sensitivity these scores are based on pathological-­anatomical
of 92–100%, thoracic ultrasound examinations changes. One of the most commonly used scoring
also seem to be suitable for the detection of pneu- systems is the thoracic Abbreviated Injury Scale
mothoraces [69, 73–75]. As a potential disadvan- (AISchest). Other anatomic scoring systems include
tage, subcutaneous emphysema aggravates an the Wagner Score [79] and the Pulmonary Contusion
accurate diagnosis by ultrasound [71]. Additionally, Score (PCS) by Tyburski [80]. Some scoring sys-
evaluation of bony lesions, as well as tube and line tems, such as the Thoracic Trauma Severity Score,
malpositioning, remains the domain of conven- also include physiological parameters [81].
tional radiography. Therefore, ultrasound exami-
nation cannot be used as an exclusive diagnostic
procedure. However, it has a supplementary role 8.4.1 Abbreviated Injury Scale
in the diagnostics of chest trauma.
The Abbreviated Injury Scale (AIS), first
described in 1969 by John D. States and revised
8.3.4 Bronchoscopy in 1998, is an anatomical scoring system allocat-
ing a severity score to every injury of different
Bronchoscopy represents both a diagnostic and body regions (head, face, neck, thorax, abdomen,
therapeutic tool. It is of particular value for the spine, upper extremity, lower extremity, external
diagnosis of tracheobronchial lesions, supraglot- and other trauma). The score value ranges from 0
tic injuries, aspiration, bleeding, and lung contu- to 6, and high severity scores are associated with
sions [76]. In addition, early diagnosis and a lower probability of survival. The AIS repre-
assessment of severity of lung contusions are sents the basis for calculation of the Injury
supposed to be more reliable by bronchoscopy Severity Score (ISS). In general, the AIS corre-
than by conventional chest radiography [77]. lates with mortality [82, 83] and the AISchest has
Besides its diagnostic use, bronchoscopy is also a been demonstrated to be an independent predic-
therapeutic tool (e.g., clearance of the respiratory tor for prolonged hospitalization [84, 85], dura-
tract, prevention of atelectasis formation, bleed- tion of mechanical ventilation [86], and a risk
ing control). Despite these advantages, indica- factor for the development of posttraumatic
tions for bronchoscopy in the acute phase after MODS [87].
trauma are rare (e.g., severe bleeding and tra-
cheobronchial ruptures). As bronchoscopy also
has the potential to enhance respiratory insuffi- 8.4.2 Pulmonary Contusion Score
ciency [78], it cannot be considered as a routinely
used tool in primary diagnostics of multiple-­ The Pulmonary Contusion Score (PCS) was devel-
trauma patients. oped in 1999 by Tyburski and colleagues [80].
8  Chest Trauma: Classification and Influence on the General Management 85

This score is based on a plain chest X-ray at the classified as mild, a value of 3–9 as moderate, and
time of admission and 24 hours after trauma. After a value of 10–18 as severe pulmonary contusion
separation of the lung into an upper, middle, and (Table 8.1). An increased severity of lung contu-
lower third, pulmonary contusions in each third sion over the first 24 h has been associated with a
are assessed by a value of 1–3. The sum of these higher mortality rate and a prolonged duration of
values represents the PCS. A PCS value of 1–2 is mechanical ventilation [80]. The PCS has been
criticized due to the weaknesses of the assessment
of pulmonary contusions by plain chest X-ray.
Table 8.1  Pulmonary contusion score by Tyburski [80]
Calculation of the pulmonary contusion score (PCS)
 Dividing the lung fields into upper, middle and lower 8.4.3 CT-Dependent Wagner Score
third
 Assigning a score of 1–3 to each region on the basis
of the amount of radiologic parenchymal changes Wagner and Jamieson developed a chest trauma
Mild pulmonary Moderate Severe score based on a CT scan [79]. In this score, the
contusion pulmonary pulmonary severity of chest trauma is classified according to
contusion contusion the volume of pulmonary lesions (Fig. 8.1).
PCS 1–2 PCS 3–9 PCS 10–18 Pulmonary lesions of ≥28% of total air space are

18%
24%

9%
24%

25%

Grad 1
• ≥ 28% of total air space consolidated or lacerated
• all patients require mechanical ventilation for
pulmonary insufficiency
Grad 2
• 19–27% of total air space consolidated or lacerated
• 60% of these patients require mechanical ventilation
for pulmonary insufficiency
Grad 3
• < 19% of total air space consolidated or lacerated
• no mechanical ventilation required for pulmonary
Fig. 8.1  CT-dependent score according to insufficiency
Wagner and Jamieson [79]
86 F. Hildebrand et al.

Table 8.2  Thoracic trauma severity score by Pape et al. [81]

Pulmonary Age
Grade PO2/FiO2 Rib fractures contusion Pleural lesion (years) Points
0 >400 0 none None <30 0
I 300–400 1–3 1 lobe unilateral Pneumothorax 30–40 1
unilateral
II 200–300 4–6 1 lobe bilateral or Hemothorax/Hemopneumothorax 41–54 2
unilateral 2 lobes unilateral unilateral
III 150–200 >3 bilateral <2 lobes bilateral Hemothorax/Hemopneumothorax 55–70 3
bilateral
IV <150 Flail chest ≥2 lobes bilateral Tension pneumothorax >70 5

classified as grade 1, 19–27% as grade 2, and <19% 8.5 Treatment

as grade 3. The authors showed an association
between the size and type of parenchymal injuries Severe chest trauma represents the second most
and the need for mechanical ventilation [79]. common diagnosis in multiple-trauma patients [5,
6]. Treatment of thoracic injuries has to be per-
formed according to established guidelines (e.g.,
8.4.4 T
 horacic Trauma Severity ABCDE-algorithm according to the Advanced
Score Trauma Life Support®, ATLS®). In this context,
chest trauma is sufficiently treated by airway con-
The Thoracic Trauma Severity Score (TTS) is a trol (e.g., intubation) and treatment of breathing
CT-independent scoring system that is based on and ventilation problems (e.g., mechanical ventila-
five anatomical and physiological parameters at tion, placement of chest tube) in >80% of the cases.
the time of admission: extent of pulmonary con- Operative interventions are required in 2–16% of
tusion, number of rib fractures, pleural lesions, patients with chest trauma. Indications for emer-
age, and PaO2/FiO2 (Horowitz) ratio [81]. Each gency surgery are penetrating or open chest trauma,
parameter is assigned a value of 0–5 (Table 8.2), hemothorax with an initial chest tube output of
and the TTS score ranges from 0 to 25. 1,000–15,000 ml, pericardial tamponade, or car-
The sensitivity and specificity of the differ- diac injury, as well as tracheobronchial or major
ent scoring systems for predicting posttraumatic vessel injuries. Indications for urgent or elective
complications and outcome have not been fully interventions include a blood loss over the chest
elucidated. In general, CT-dependent scores are tube of >200 ml/h over 5 h or >400 ml/h over 2 h,
thought to be more reliable for the assessment diaphragmatic or esophageal lesions, persistent
of trauma severity and susceptibility to post- bronchopleural leakage, pneumato- or hemato-
traumatic complications (e.g., ARDS). In con- celes, valvular damage, non-drainable clots, and
trast, CT-independent scoring systems might be flail chest. In an emergency situation, anterolateral
helpful for early evaluation of the risk profile at thoracotomy represents the standard approach,
admission after chest trauma. However, it has whereas the posterolateral approach is favored in
been suggested that these scores should be the hemodynamically stable patient.
based on anatomical and physiological parame- There is also a high coincidence of thoracic
ters due to the limited diagnostic value of con- injuries and extremity trauma (e.g., femoral frac-
ventional chest X-ray. Recently, the predictive tures). The timing and type of fracture stabiliza-
value of the PCS, the Wagner score, and the tion have the potential to substantially influence
TTS score was analyzed [88], and it was shown pulmonary function as well as the development
that the TTS score best predicts ARDS, MODS, of posttraumatic complications in multiple-­
and in-­ hospital mortality in multiple-trauma trauma patients with chest trauma. Therefore,
patients [88]. this chapter focuses on both the general aspects
8  Chest Trauma: Classification and Influence on the General Management 87

of the treatment of chest trauma and the signifi- p­ arenchyma. Therefore, lung protective ventila-
cance of adequate treatment strategies for frac- tion with low tidal volumes (5–6 ml/kg), high
ture stabilization in cases of concomitant chest positive end-expiratory pressure (PEEP), and
trauma. limited inspiratory peak pressure (<35 cm H20)
should be used in case of severe chest trauma.

8.5.1 Airway Management

8.5.3 Positioning Therapy
Usually, oral intubation is already performed at
the scene of the accident or in the emergency Positioning therapy has been applied in patients
department. If not, it has to be considered in the with chest trauma to prevent and treat pulmonary
initial posttraumatic period as early intubation functional disorders. There are a variety of posi-
has been shown to reduce morbidity and mortal- tioning procedures including the semi-recumbent
ity in patients with severe chest trauma. position, the lateral position, the prone position,
Indications for intubation include TBI (Glasgow and continuous axial rotational therapy.
Coma Scale <9), chest trauma with respiratory Mechanically ventilated patients should always
insufficiency (e.g., SaO2 <90%, breathing rate be positioned in a semi-recumbent position (45°)
<10/min or >30/min), hemorrhagic shock, and in order to avoid pulmonary aspiration and
cardiopulmonary reanimation. In cases of a sus- ventilator-­associated pneumonia. In patients with
pected ventilation time of more than 7–10 days, unilateral lung injuries, lateral positioning of
tracheotomy has been recommended. almost 90° (“good lung down”) has been
Tracheotomy seems to be favorable due to recommended.
improvements in respiratory mechanics and the A complete prone position is the 180° con-
reduction of infectious complications. However, trast to the supine position, meaning that the
the effect of tracheotomy on total ventilation time patient lies with the chest down and back up.
and the duration of intensive care treatment have An incomplete prone position is a transfer
been controversially discussed. between 130° and <180°. Prone positioning is
applied in patients that suffer from severe
ARDS with life-­threatening hypoxemia (PaO2/
8.5.2 Mechanical Ventilation FiO2 <100). Contraindications for prone posi-
tioning include an open abdomen, unstable
In the anesthetized, mechanically ventilated spine injuries, TBI with increased intracerebral
patient, a reduction in pulmonary functional pressure, severe arrhythmia, acute shock, and
residual capacity due to supine positioning has substantial facial trauma [89–91]. Prone posi-
been observed. Furthermore, a posttraumatic tioning is recommended for at least 12 h. It
reduction in the compliance results in hypoventi- results in an increase in pulmonary gas
lated areas, particularly in dorsobasal lung sec- exchange due to an improved ventilation/perfu-
tions, with an increased risk for atelectasis sion ratio [92–94] and recruitment of alveolar
formation. As these lung sections show the best space with reduced atelectasis formation [95–
pulmonary perfusion, a ventilation/perfusion 99]. These effects occur either immediately
mismatch with increased intrapulmonary shunt- (≤30 min) or up to 12 h after retransfer into a
ing is also observed. Additionally, the increased supine position [100–102]. Incomplete prone
intrathoracic pressure due to mechanical ventila- positioning is less effective [103]. Compared to
tion exerts hemodynamic effects, such as continuous axial rotational therapy, prone posi-
decreased cardiac output. Besides trauma-related tioning seems to be associated with stronger
pulmonary injuries, mechanical ventilation with and faster therapeutic effects. However, no dif-
high inspiratory pressure also has the potential to ferences are evident between these positioning
result in additional damage to the lung procedures after 72 h [104].
88 F. Hildebrand et al.

Overall, it seems noteworthy that, if applied inhomogeneous study populations, a generaliza-

correctly, prone positioning represents a rela- tion of these results to the treatment of severe blunt
tively safe procedure that does not result in a chest trauma patients is questionable. Nevertheless,
significant increase in intra-abdominal pressure the role of kinetic therapy and its prognostic rele-
in patients without abdominal injuries [105, vance should be clarified in further studies.
106]. However, it can be complicated by facial Furthermore, reliable parameters for the indication
edema (20–30%), pressure ulcers (20%), non- of kinetic therapy should be validated.
compliance of the patient (20%), and arrhyth-
mia (5%), as well as by tube and catheter
dislocation (1–2%) [107]. Despite improved 8.5.4 Fracture Treatment
arterial oxygenation, prone positioning does not in Multiple-Trauma Patients
result in a significant reduction of morbidity, with Thoracic Trauma
ventilation time, or length of stay in the inten-
sive care unit in patients with ARDS [107, 108]. In patients with severe abdominal injuries and
In contrast, a decrease in ventilator-­associated hemodynamic instability, initial management
pneumonia after prone positioning has been should avoid complex operative procedures.
described [107, 108]. Such interventions in the acute phase have to be
Continuous axial rotational therapy is char- performed rapidly and should not add a further
acterized by continuous rotation of the patient significant burden to the patient. The primary
about the longitudinal axis in a self-rotating focus under these conditions is hemorrhage con-
bed. Depending on the different bed systems, a trol and the performance of other life-saving pro-
rotation of up to 62° to each side can be cedures. Complex reconstructive work is delayed
achieved. Potential indications are the preven- until the patient is able to withstand the additional
tion of pulmonary complications (e.g., atelecta- surgical trauma. This “damage control” approach
sis, pneumonia) in patients with chest trauma has been adapted to patients with extremity
[109–111]. Furthermore, it is used for the treat- trauma. In specific subgroups of these patients,
ment of ARDS if, for example, prone position- extensive surgical procedures for fracture stabili-
ing is contraindicated. Kinetic therapy is zation have been associated with an increased
recommended for at least 3–5 days [109–111]. incidence of complications, such as SIRS and
The best effects of axial rotational therapy MODS.
[110–115] are described for a rotation of >40° In general, there are two treatment strategies
to each side. Contraindications are unstable for fracture care in multiple-trauma patients. The
spine injuries, acute shock, and adiposity aforementioned concept of “damage control
(≥160 kg). Complications associated with orthopedics” (DCO) is characterized by tempo-
kinetic therapy include pressure ulcers, hemo- rary external fracture fixation in the primary phase
dynamic instability, kinetosis, and catheter with secondary conversion to definitive osteosyn-
dislocation. thesis after stabilization of the patient’s physio-
The potential benefits of continuous axial rota- logical and immunological status in the intensive
tional therapy have been discussed controversially care unit. In contrast, primary definitive fracture
[116]. Besides the positive effects observed in fixation is performed within the concept of “early
some studies, other trials failed to show a signifi- total care” (ETC) [125–130]. Although early frac-
cant effect on morbidity, ventilation time, and ture fixation has been described to be essential to
length of stay in the intensive care unit [117–122]. avoid pulmonary complications after multiple
Furthermore, recent studies did not find a benefi- traumas [131, 132], the optimal treatment strategy
cial effect of mechanical ventilation with prophy- (ETC versus DCO) for fracture care remains the
lactic kinetic therapy compared to early extubation focus of intensive research [125–133]. This is par-
and aggressive weaning in patients with severe ticularly true for multiple-­trauma patients with
thoracic trauma [123, 124]. Due to the small and severe chest trauma [133]. Several investigations
8  Chest Trauma: Classification and Influence on the General Management 89

have demonstrated a decreased risk for infection multiple-trauma patients. The timing of
and pulmonary dysfunction after ETC treatment ­secondary definitive osteosynthesis within the
in these patients [125, 129, 134, 135], whereas DCO concept seems to not be advantageous
other studies have reported an increased rate of before 5 days after the trauma [128, 139].
pulmonary failure after ETC. Accordingly, an Giannoudis recommended secondary fracture
inconsistent use of ETC and DCO has been shown fixation based on defined parameters (Table
in an analysis of the trauma registry of the German 8.4) [139].
Trauma Society in patients with chest trauma In conclusion, early definitive fracture
[128, 133, 136, 137]. ­stabilization seems to increase the risk of adverse
In the majority of studies, it is accepted that outcome in multiple-trauma patients with severe
stable patients benefit from the ETC concept, chest trauma. However, further prospective ran-
whereas unstable patients and patients “in domized studies are needed to increase the sensi-
extremis” might benefit from DCO. In a pro- tivity and specificity of parameters to identify
spective randomized study, Pape et al. [138] those patients who might benefit from the DCO
introduced an additional group of patients that concept of fracture care. Recently, further treat-
were in an unclear condition (“borderline” ment strategies for fracture stabilization in
patients; Table 8.3). These patients were distin- multiple-­trauma patients, including “early appro-
guished from stable, unstable, and “in extre- priate care” (EAC) and “safe definitive surgery”
mis” patients (Fig. 8.2). In this study, borderline (SDS), have been developed [140–144]. The
patients were shown to have a significantly
higher incidence of acute lung injury (ALI) Table 8.3  Borderline patients according to Pape et al. [138]
after ETC treatment compared to fracture stabi- ISS >40
lization according to the DCO concept [128]. Hypothermia <35 °C
For the identification of these patients, the Multiple trauma with ISS >20 and AISchest >2
severity of thoracic trauma and physiological Multiple trauma with abdominal/pelvic injury (AIS >
pulmonary parameters are of central i­ mportance. 2) and shock (RRsystol <90 mmHg)
This emphasizes the significance of chest Bilateral lung contusion in chest radiography or CT
trauma for the development of posttraumatic Pulmonary artery pressure (PAP) >24 mmHg
complications after fracture stabilization in Increase of PAP >6 mmHg during femoral nailing

Polytraumatized patient

Clinical conditions

stable borderline patient instable in extremis

Emergency room
Bleeding control
Thoracic release

Clinical reevaluation
OP (RR, blood gas, urinary OP ICU
assessment, ultrasonography) External fixation

stable uncertain
Fig. 8.2 Treatment
algorithm according to
Pape et al. [138] ETC ETC DCO DCO
90 F. Hildebrand et al.

Table 8.4  Signs of stabilization according to Giannoudis p­ erformed early (24–72 hours after injury), and
[139]
no additional lung contusions or severe TBI was
Hemodynamic stability present [147, 148].
Stable arterial oxygenation
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 Abdominal Compartment
Syndrome
9
Rao R. Ivatury

9.1 Introduction

Abdominal compartment syndrome (ACS) has

Abdominal hypertension
Normal
Organ dysfunction Abdominal
tremendous relevance in the care of critically ill abdominal compartment
or injured patients, because of the effects of ele- pressure syndrome
vated pressure within the confined space of the
abdomen on multiple organ systems. Our knowl-
edge of this lethal syndrome has evolved over the
past 15 years. Of note, we now recognize that
ACS should be viewed as the end result of a pro-
gressive, unchecked rise in IAP, called intra-­
abdominal hypertension (IAH), as illustrated in 0 5 10 15 20 25 30 35 40
Fig. 9.1. We also have learnt that the adverse IAP
effects of elevated IAP occur at lower levels than
previously thought [1]. Fig. 9.1  Progression of IAP (intra-abdominal pressure)
from normal to IAH (intra-abdominal hypertension) to
abdominal compartment syndrome with organ failures

9.2 Historical Background

(1981), Harman (1982), Richards (1983), and Kron,
The pathophysiology of IAH has been known since Harman, and Nolan (1984) were the greatest con-
late 1800s [1]. Marey (1863), Braune (1865), Schatz tributors in the field. Fietsam et al. from William
(1872), Wendt of Germany (1873), Oderbrecht of Beaumont Hospital, Royal Oak, Michigan, were the
Germany (1875), Quinke of Germany (1878), architects of the term intra-abdominal compartment
Mosso and Pellacani of Italy (1882), and Heinricius syndrome [2]. They described it: “In four patients
of Germany (1890) all described the ill effects of with ruptured abdominal aortic aneurysms….mani-
IAH. In the next century, Emerson (1911), Bradley fested by increased ventilatory pressure, increased
(1947), Gross (1948), Olerud (1953), Kashtan central venous pressure, and decreased urinary out-
put associated with massive abdominal distension
not due to bleeding. This set of findings constitutes
R.R. Ivatury, MD, FACS, FCCM an intra-abdominal compartment syndrome …
Virginia Commonwealth University, Opening the abdominal incision was associated with
Richmond, VA, USA dramatic improvements.” As with many advances in
e-mail: raoivatury@gmail.com

© Springer International Publishing AG 2017 97

H.-C. Pape et al. (eds.), Damage Control Management in the Polytrauma Patient,
DOI 10.1007/978-3-319-52429-0_9
98 R.R. Ivatury

medicine, this precious knowledge was forgotten, after ensuring that abdominal muscle contrac-
rediscovered, and forgotten again. Many proponents tions are absent and with the transducer zeroed at
of the syndrome faced skepticism and ridicule till the the level of the midaxillary line. The reference
clinical syndrome was rediscovered in patients with standard for intermittent IAP measurement is via
life-threatening abdominal injuries undergoing the bladder with a maximal instillation volume of
“damage-control” surgery. In this group of patients, 25 mL of sterile saline. Normal IAP is approxi-
IAH became a prime cause of avoidable morbidity mately 5–7 mmHg in critically ill adults.
and mortality [3–11].
Our knowledge of IAH and ACS was spurred IAH  Intra-abdominal hypertension is defined by
by the shared experiences of trauma centers deal- a sustained or repeated pathologic elevation of
ing with the nightly horrors of “America’s uncivil IAP ≥12 mmHg. It is graded as follows: grade I,
war” (CW Schwab). The phenomena were codi- IAP 12–15 mmHg; grade II, IAP 16–20 mmHg;
fied by trauma surgeons who popularized the grade III, IAP 21–25 mmHg; and grade IV, IAP
clinical practice of such advances as IAP monitor- >25 mmHg.
ing by bladder pressure and non-closure of fascia
after laparotomy (“open abdomen”). The conse- ACS  Abdominal compartment syndrome (ACS)
quent results were nothing short of dramatic [3, 4, is defined as a sustained IAP >20 mmHg (with or
8]. Further advances were also realized through without an APP [MAP-IAP] <60 mmHg) that is
the efforts of a remarkable group of clinical associated with new organ dysfunction/failure. It
researchers interested in the subject. After a pre- should be noted that this definition moves ACS to
liminary meeting in 2001 in Sydney, Sugrue and a much earlier point in the trajectory of clinical
associates formally established the World Society course than the traditional fully manifested syn-
of Abdominal Compartment Syndrome (WSACS) drome with multiorgan failure.
in 2004 in Noosa in Australia. This society, though Primary ACS is a condition associated with
a small group of motivated intensivists, redefined injury or disease in the abdominopelvic region
the current concepts of IAH and ACS through that frequently requires early surgical or inter-
multinational clinical trials, literature review and ventional radiological intervention.
analysis, multiple publications including a mono- Secondary ACS refers to conditions that do
graph on the subject [1] and guideline and con- not originate from the abdominopelvic region.
sensus development [12–15]. Recurrent ACS refers to the condition in which
With this historic background, this chapter ACS redevelops following previous surgical or
will summarize the WSAC consensus definitions, medical treatment of primary or secondary ACS.
a brief review of pathophysiology, and WSACS
recommendations and algorithms. It will then Risk Factors for IAH/ACS [12–15]  ACS can
evaluate their impact on the current status of IAH develop in both nonsurgical and surgical patients.
in critically injured or ill patients and offer some These factors include diminished abdominal wall
projections for the future. The issues of “open compliance (abdominal surgery, major trauma,
abdomen” approach for prevention of IAH and major burns, prone positioning), increased intra-
ACS, while highly relevant, are beyond the scope luminal contents (e.g., acute pancreatitis, hemo-
of this chapter, however. peritoneum/pneumoperitoneum or intraperitoneal
fluid collections, intra-abdominal i­ nfection/
abscess, intra-abdominal or retroperitoneal
9.3  urrent Definitions of IAH
C tumors, liver dysfunction/cirrhosis with ascites,
and ACS [12, 13] capillary leak/fluid resuscitation from massive
fluid resuscitation or positive fluid balance), and
IAP  Intra-abdominal pressure (IAP) is the pres- damage-control laparotomy. Other miscellaneous
sure concealed within the abdominal cavity. IAP causes include bacteremia, coagulopathy, mas-
should be expressed in mmHg and measured at sive incisional hernia repair, obesity or increased
end expiration in the complete supine position body mass index, PEEP, peritonitis, and sepsis.
9  Abdominal Compartment Syndrome 99

9.4 Pathophysiology of ACS 9.4.3 Renal Sequelae

IAH affects multiple organ systems in a graded Oliguria progressing to anuria and prerenal azo-
fashion. temia unresponsive to volume expansion charac-
terize the renal dysfunction of ACS [1, 9–18].
Oliguria can be seen at IAP of 15–20 mmHg,
9.4.1 Cardiovascular Effects while increases to 30 mmHg or above lead to
anuria. Volume expansion to a normal CO and the
Elevation in IAP leads to a reduction in cardiac use of dopaminergic agonists or loop diuretics
output (CO) [9–11], most consistently seen at may be ineffective in these patients. However,
an IAP >20 mmHg. This is due to a combina- decompression and reduction in IAP promptly
tion of decreased inferior vena caval flow and reverses oliguria, usually inducing a vigorous
an increased thoracic pressure (which decreases diuresis [17, 18]. The mechanisms of renal
both inferior and superior vena caval flow). derangements with IAH involve reduced absolute
Other contributory factors include cardiac com- and proportional renal arterial flow, increased
pression, decreased ventricular end-diastolic renal vascular resistance with changes in intrare-
volumes, and marked increase in systemic nal regional blood flow, reduced glomerular fil-
afterload. This may lead to spuriously elevated tration, and increased tubular sodium and water
central venous pressure, pulmonary artery pres- retention [1, 17, 18].
sure, and pulmonary artery occlusion (“wedge”)
pressure. Combined with a reduced CO, this
may erroneously suggest a state of hypervol- 9.4.4 Abdominal Visceral
emia or biventricular failure [1, 9–11]. Abnormalities
Improvement in CO after a saline fluid bolus
may be therapeutic and clarify the diagnostic Mesenteric arterial, hepatic arterial, intestinal
conundrum. mucosal, hepatic microcirculatory, and portal
venous blood flow all have been shown to be
reduced with IAH in animal models [19, 20].
9.4.2 Pulmonary Dysfunction Clinically, many investigators demonstrated that
gut mucosal acidosis, demonstrable by intramu-
With an acute elevation in IAP, respiratory failure cosal pH (pHi) measured with gastric tonometry,
characterized by high ventilatory pressures, is a sensitive change after ACS [1, 4, 21]. Further
hypoxia, and hypercarbia eventually develops increases in IAP may lead to intestinal infarction,
[9–11]. Diaphragmatic elevation leads to a reduc- often present in the ileum and right colon without
tion in static and dynamic pulmonary compli- arterial thrombosis. Prolonged low-grade eleva-
ance. The increase in IAP also reduces total lung tion of IAP may be associated with bacterial
capacity, functional residual capacity, and resid- translocation in rat and murine models [22].
ual volume [9–11]. These lead to ventilation-­ Thus, despite normal systemic hemodynamics,
perfusion abnormalities and hypoventilation profound splanchnic ischemia can be ongoing
producing hypoxia and hypercarbia, respectively. with IAH. It has been suggested that such isch-
A porcine model by Simon et al. demonstrated emia is associated with an increased incidence of
that prior hemorrhage and resuscitation multisystem organ failure, sepsis, and increased
(ischemia-­reperfusion injury) exacerbate the car- mortality [1, 4, 9–11]. Furthermore, laboratory
diopulmonary sequelae of IAH [16]. Chronic evidence suggests that prior hemorrhage and
elevation of IAP, as in central obesity, also pro- resuscitation actually lowers the critical levels of
duces these derangements in the form of obesity IAP at which mesenteric ischemia begins [23].
hypoventilation syndrome (OHS) [11]. Many investigators note a relationship between
Abdominal decompression improves the acute IAH, sepsis, multisystem organ failure, and the
respiratory failure almost immediately [9–11]. need for reoperation and mortality. These are
100 R.R. Ivatury

some of the strongest arguments for the routine ion of IAH, e.g., intra-abdominal leading to intra-
measurement of IAP in critically ill patients. thoracic and consequent intracranial hypertension.
IAH helps to explain the severe pathophysiologi-
cal condition occurring in patients with cardiore-
9.4.5 Abdominal Wall nal, hepatopulmonary, and hepatorenal
Abnormalities syndromes. When more than one compartment is
affected, an exponential detrimental effect on
Increased IAP has been shown to reduce abdomi- end-organ function in both immediate and distant
nal wall blood flow by the direct, compressive organs may occur. The compliance of each com-
effects of IAH under conditions of stable sys- partment is the key to determining the transmis-
temic perfusion, leading to local ischemia and sion of a given compartmental pressure from one
edema [24]. This can decrease abdominal com- compartment to another. In high-risk patients,
pliance (defined as a measure of the ease of these interactions must be considered for optimal
abdominal expansion, which is determined by the management [25].
elasticity of the abdominal wall and diaphragm
and expressed as the change in intra-abdominal
volume per change in IAP) and exacerbate 9.5 Recommendations
IAH. Abdominal wall muscle and fascial isch- in Management
emia may contribute to such wound complica-
tions as dehiscence, herniation, and necrotizing The following are the recommendations from
fasciitis. WSACS [13] in the clinical pursuit of IAH and
ACS based on the GRADE methodology (grad-
ing, assessment, development, and evaluation).
9.4.6 Intracranial Derangements Quality of evidence is graded from high (A) to
very low (D). Recommendations range from
Elevated intracranial pressure (ICP) and reduced strong recommendations to weaker suggestions.
cerebral perfusion pressure (CPP) have been The recommendations include use of proto-
described with acute changes in IAP in animal colized monitoring and management of IAP
models and in human studies [25]. In animal [GRADE 1C], efforts and/or protocols to avoid
models, the changes in ICP and CPP are indepen- sustained IAH among critically ill or injured
dent of changes in pulmonary or cardiovascular patients [GRADE 1C], decompressive laparot-
function and appear to be the direct result of ele- omy [27] in cases of overt ACS [GRADE 1D],
vated intrathoracic and central venous pressures conscious and/or protocolized efforts be made
with impairment of cerebral venous outflow. among ICU patients with open abdominal
Reduction in IAP by surgical decompression wounds to obtain an early or at least
reverses this derangement. Furthermore, chronic ­same-­hospital-­stay abdominal fascial closure
elevation in IAP has been implicated as an impor- [GRADE 1D], and among critically ill/injured
tant etiologic factor in the development of benign patients with open abdominal wounds, use of
intracranial hypertension, or pseudotumor cere- strategies utilizing negative pressure wound ther-
bri, in the morbidly obese [11]. apy [GRADE 1C].
The suggestions include the following: clini-
cians ensuring that critically ill or injured patients
9.4.7 Polycompartment receive optimal pain and anxiety relief [GRADE
Syndrome [25] 2D]; brief trials of neuromuscular blockade as a
temporizing measure in the treatment of IAH/
A polycompartment syndrome, where two or ACS [GRADE 2D]; considering the potential
more anatomical compartments have elevated contribution of body position to elevated IAP
compartmental pressures, is a potential compan- among patients with, or at risk of, IAH or ACS
9  Abdominal Compartment Syndrome 101

[GRADE 2D]; liberal use of enteral decompres- 9.7  urrent Status of IAH
C
sion with nasogastric or rectal tubes when the and ACS
stomach or colon is dilated in the presence of
IAH/ACS [GRADE 1D]; neostigmine be used As noted earlier, the efforts of WSACS made a
for the treatment of established colonic ileus not profound impact on our understanding of the dis-
responding to other simple measures and associ- ease and our clinical approach. Anticipation of
ated with IAH [GRADE 2D]; using a protocol to the complication, measures of prophylaxis, ear-
try and avoid a positive cumulative fluid balance lier recognition, and intervention: all of these
in the critically ill or injured patient with, or at translated into fewer organ failures and better
risk of, IAH/ACS after the acute resuscitation has survival. The complications of the open abdomen
been completed [GRADE 2C]; use of an may be offsetting some of these  benefits. More
enhanced ratio of plasma/packed red blood cells advanced care of “laparotomy,” however, is min-
for resuscitation of massive hemorrhage versus imizing this weakness.
low or no attention to plasma/packed red blood In a prospective, observational study,
cell ratios [GRADE 2D]; use of percutaneous Cheatham and Safcsak [28] studied 478 con-
decompression to remove fluid (in the setting of secutive patients who were treated with open
obvious intraperitoneal fluid) in those with IAH/ abdomen for IAH and ACS according to “a con-
ACS as, when this is technically possible tinually revised management algorithm” and
[GRADE 2C], this may also alleviate the need for noted a significantly increased patient survival
decompressive laparotomy [GRADE 2D]; trauma to hospital discharge from 50% to 72%
patients with physiologic exhaustion undergoing (p = 0.015) and an increase in same-admission
abbreviated laparotomy be treated with the pro- primary fascial closure from 59% to 81% over
phylactic use of the open abdomen and expectant the period of the study, one of the first clinical
IAP management [GRADE 2D]; not routinely series showing better outcomes with a manage-
utilizing the open abdomen for patients with ment focus on IAP that did not increase resource
severe intraperitoneal contamination undergoing utilization. Balogh and associates [29] prospec-
emergency laparotomy for intra-abdominal sep- tively analyzed 81 consecutive severely injured
sis unless IAH is a specific concern [GRADE shock/trauma patients (mean ISS 29) admitted
2B]; and avoiding the routine use of bioprosthetic to the intensive care unit. They had a protocol of
meshes in the early closure of the open abdomen two-hourly intra-abdominal pressure (IAP)
compared to alternative strategies [GRADE 2D]. monitoring. No patient developed ACS, even
The WSACS noted that the evidence did not though 61 (75%) had IAH. One patient with
support any recommendations about the use of IAH and one without died. Multiorgan failure
abdominal perfusion pressure (MAP-IAP) in the occurred in one patient without IAH (5%) vs. 4
resuscitation or management of the critically ill with IAH (7%). The authors commented that
or injured and the use of diuretics, albumin, or monitoring and intervening for a less serious
renal replacement therapy to mobilize fluids in IAH and the avoidance of the deadly ACS are
hemodynamically stable patients with IAH after remarkable successes of critical care in the last
the acute resuscitation has been completed. decade. Recent evidence concluded that the cur-
rent practice of restricted fluid resuscitation and
liberal use of damage-­control strategies among
9.6  anagement of IAH
M trauma patients along with monitoring for IAH
and ACS [13] has lowered the prevalence of ACS [30]. While
established trauma centers and academic insti-
The most effective approach in the management tutions were eliminating ACS by aggressive
of IAH and ACS is best summarized by the application of the concepts narrated in this
algorithms recommended by WSACS (Figs. 9.2 chapter, these paradigms apparently have yet to
and 9.3). be promulgated widely.
102 R.R. Ivatury

Intra-Abdominal Hypertension (IAH) / Abdominal

Compartment Syndrome (ACS) Management algorithm

Medical treatment options to reduce IAP

Patient has IAH
NO 1. Improve abdominal wall compliance
(IAP ≥ 12 mmHg)
Sedation & analgesia
Neuromuscular blockade
Initiate treatment to reduce IAP
Intra-Abdominal Hypertension (IAH)

Avoid head of bed > 30 degrees

Avoid excessive fluid 2. Evacuate intra-luminal contents
resuscitation
Nasogastric decompression
Optimize organ perfusion
Rectal decompression
(GRADE 1C)
Gastro-/colo-prokinetic agents
3. Evacuate abdominal fluid collections
Monitor IAP with Paracentesis
IAP > serial measurements Percutaneous drainage
20 mmHg at least every 4 IAP < 12 mmHg 4. Correct positive fluid balance
with new organ NO Avoid excessive fluid resuscitation
hours while patient is consistently?
failure? critically ill Diuretics
(GRADE 1C) Colloids / hypertonic fluids
Hemodialysis / ultrafiltration
YES 5. Organ Support
YES Optimize ventilation, alveolar recruitment
Use transmural (tm) airways pressure
IAH has resolved
Pplattm = Plat - 0.5 * IAP
Discontinue IAP measurements
Patient has ACS Consider using volumetric preload indices
and monitor patient for
clinical deterioration
If using PAOP/CVP, use transmural pressures
PAOPtm = PAOP - 0.5 * IAP
CVPtm = CVP - 0.5 * IAP

IDENTIFY AND TREAT

UNDERLYING ETIOLOGY Definitions
FOR PATIENT’S ACS IAH - intra-abdominal hypertension
ACS - abdominal compartment syndrome
IAP - intra-abdominal pressure
Does
patient have Patient has Secondary or APP - abdominal perfusion pressure (MAP-IAP)
NO
primary ACS? Recurrent ACS Primary ACS - A condition associated with injury
or disease in the abdomino-pelvic region that
Abdominal Compartment Syndrome (ACS)

frequently requoires early surgical or

interventional radiological intervention
YES
Secondary ACS - ACS due to conditions that do
not originate from the abdomino-pelvic region
Perform / revise abdominal Is IAP
decompression with temporary > 20 mmHg with Recurrent ACS - The condition in which ACS
YES redevelops following previous surgical or
abdominal closure as needed to progressive organ
reduce IAP (GRADE 2D) failure medical treatment of primary of secondary ACS

NO

Continue medical treatment options to reduce IAP

(GRADE 1C)

Measure IAP at least every 4 hours while patients is critically ill

(GRADE 1C)

Perform balanced resuscitation of patient preload, contractility, and

afterload using crystalloid / colloid / vasoactive medications
AVOID EXCESSIVE FLUID RESUSCITATION (GRADE 2D)

IAH has resolved

Is IAP > 20 Decrease frequency of IAP
mmHg with Is IAP < 12 mmHg YES
NO measurements and observe
organ failure? consistently?
patient for deterioration

Fig. 9.2  Management algorithm for IAH and ACS (Reproduced from Kirkpatrick et al. [13])
9  Abdominal Compartment Syndrome 103

IAH/ ACS medical management algorithm

• The choice (and success) of the medical management strategies listed below is strongly related to both the etiology of
the patient’s IAH / ACS and the patient’s clinical situation. The appropriateness of each intervention should always be
considered prior to implementing these interventions in any individual patient.
• The interventions should be applied in a stepwise fashon until the patient’s intra-abdominal pressure (IAP) decreases.
• If there is no response to a particular intervention, therapy should be escalated to the next step in the algorithm.

Patient has IAP ≥ 12 mmHg

Begin medical management to reduce IAP
(GRADE 1C)

Measure IAP at least every 4-6 hours or continuously.

Titrate therapy to maintain IAP ≤ 15 mmHg (GRADE 1C)

Evacuate intra-
Evacuate intraluminal Improve abdominal Optimize fluid Optimize systemic /
abdominal space
contents wall compliance administration regional perfusion
occupying lesions

Ensure adequate Avoid excessive fluid

Insert nasogastric Abdominal ultrasound Goal-directed fluid
sedation & analgesia resuscitation
and/or rectal tube to identify lesions resuscitation
(GRADE 1D) (GRADE 2C)
Step 1

Initiate gastric-/colo- Remove constrictive Aim for Zero to

prokinetic agents dressings, abdominal negative fluid balance
(Grade 2D) eschars by day 3 (GRADE 2C)

Abdominal computed Consider reverse Resuscitate using Hemodynamic

Minimize enteral
tomography to Trendelenberg hypertonic fluids, monitoring to guide
nutrition
identify lesions position colloids resuscitation
Step 2

Percutaneous Fluid removal through

Administer enemas
catheter drainage judicious diuresis
(GRADE 1D)
(GRADE 2C) once stable

Consider colonoscopic Consider surgical Consider Consider

decompression evacuation of lesions neuromuscular hemodialysis /
(GRADE 1D) (GRADE 1D) blockade (GRADE 1D) ultrafiltration
Step 3

Discontinue enteral
Nutrition
Step 4

If IAP > 20 mmHg and new organ dysfunction / failure in present, patient’s IAH / ACS is refractory to medical management. Strongly
consider surgical abdominal decompression (GRADE 1D)

Fig. 9.3  Medical management of IAH and ACS (Reproduced from Kirkpatrick et al. [13])
104 R.R. Ivatury

9.8  wareness and Appreciation

A References
of IAH and ACS
1. Ivatury RR, Cheatham M, Malbrain M, Sugrue
In 2013 the WSACS distributed a survey of 13 M. Abdominal compartment syndrome. Austin:
questions to 10,000 members of the WSACS, the R. Landes Publishers; 2006.
2. Fietsam R, Billalba M, Glover JL, et al. Intra-­
European Society of Intensive Care Medicine abdominal compartment syndrome as a complication
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of the innovation of damage control for manage-
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Overall knowledge scores were low (43 ± 15%). abdominal hypertension after life-threatening pene-
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(49.6% vs. 38.6%, P < 0.001), suggesting igno- 1016–21.
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Another survey tried to clarify the current under- 8. Schwab CW. Master surgeon lecture: damage control:
standing and clinical management of intra-abdom- 20 years of experience. aast.org. Accessed 31 May 2016.
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application of definitions and guidelines was 597–609.
12. Cheatham ML, Malbrain ML, Kirkpatrick A, et al.
reported among German pediatric intensivists [34] Results from the International Conference of Experts
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13. Kirkpatrick AW, Roberts DJ, De Waele J, et al. Intra-­
patients, medical or surgical, young or old. They abdominal hypertension and the abdominal compart-
can cause profound morbidity and mortality, if ment syndrome: updated consensus definitions and
unanticipated, unrecognized, and uncontrolled. clinical practice guidelines from the World Society of
Appropriate monitoring and early intervention, the Abdominal Compartment Syndrome. Intensive
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organ failures, morbidity, and mortality. It abdominal hypertension and abdominal compartment
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current knowledge of IAH and ACS is yet incom- Anaesthesiol Intensive Ther. 2015;47(3):219–27.
doi:10.5603/AIT.a2015.0027. Epub 2015 May 14.
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 Orthopaedic Surgery Approach
to Damage Control: Decision-­
10
Making and Indications

Marius Keel and Hans-Christoph Pape

10.1 Introduction Table 10.1  Evidence-based definition of polytrauma

AIS >2 points and at least one of the following
Decision-making may include several processes, covariables
such as assessment of the patient, assessment of Hypotension (systolic blood pressure <90 mm Hg)
the surgeries and the resources required, and the Level of consciousness (Glasgow Coma Scale [GCS]
perspective of management. It requires the score <8)
Acidosis (base excess ≥6.0)
vision, the knowledge and the skills of an expe-
Coagulopathy (international normalized ratio 1.4/
rienced trauma surgeon or of a trained team of partial thromboplastin time >40 s)
specialized surgeons according to the injury pat- Age (>70 years)
tern. In this line, the concept of the borderline
trauma patient respects the fact that the patient acidosis, coagulopathy and age [1] (Table 10.1
status can change over time and may affect the and Fig. 10.1).
decision-­making process. The widely used con- The measurement of inflammatory markers
cept relies on the triad of death and the factor of that highlight patients at risk is helpful in decid-
organ and soft tissue injuries, which may include ing which patients are best served by damage
head, abdominal or chest trauma as well as control surgery. The use of a single parameter is
severe extremity injuries and complex spinal and inappropriate, as multiple factors can influence
pelvic trauma. It is interesting to note that the the course in multiple ways.
only evidence-­ based definition of polytrauma These are best described for the triad of death
summarizes a number of parameters rather than (shock, hypothermia, coagulopathy):
just a single one: cofactors were calculated on
the basis of a nationwide registry. Five indepen- 1. Hypothermia is known to affect coagulation
dent ­physiologic variables were identified as and does not address the clinical situation
follows: hypotension, level of consciousness,
­ completely, if addressed alone [2]. It has to be
viewed and treated within the general context.
M. Keel 2. Coagulopathy affects several other pathways,
Department of Orthopaedics and Trauma,
Inselspital, Berne, Switzerland
such as the cellular energy turnover, the cardiac
e-mail: marius.keel@insel.ch effects induced by hypothermia. This may not
H.-C. Pape, MD, FACS (*)
allow for safe definitive surgery (see below) [3].
Professor and Chairman, Department of Trauma, 3. Shock belongs to the triad of death as well, and
Zurich University, Raemistr. 100, 8091 Zurich, the parameter used the most is serum ­lactate.
Switzerland However, care should be taken not to rely on
e-mail: papehc@aol.com

© Springer International Publishing AG 2017 107

H.-C. Pape et al. (eds.), Damage Control Management in the Polytrauma Patient,
DOI 10.1007/978-3-319-52429-0_10
108 M. Keel and H.-C. Pape

Fig. 10.1  Four vicious Obstruction Mediator release

cycles

Hypoxemia Hypoxemia
Coagulopathy Shock, blood loss

Permeability
Endothelial damage

Immune dysfunction

Hypothermia Mediator Soft tissue injuries

release (major fx., lung contusion)

Coagulation inflammation Tissue necrosis, hypoxemia

lactate alone: Various metabolites may affect Table 10.2 Recommendations to consider damage
the measurement of metabolic acidosis [4]. ­control within the safe definitive surgery concept
Elderly with chronic diseases – such as renal Parameter/clinical
failure – may demonstrate pathological lactate diagnosis Recommendation
values [5]. These factors contribute to the gen- Head injury Degree unclear in the literature,
no recommendation possible
eral inflammatory response after trauma.
Bilateral lung TTS score [10]
4. Soft tissue, respectively, organ injuries of the contusions
head, abdomen, chest, spine, pelvis and the Estimated operation Includes visceral operations,
extremities are parameters of the first trauma time of >6 h followed by orthopaedics [11]
hit that put the patient at risk as summarized Multiple long bone >2 of the lower extremity
below [6–8]. injuries
Hypothermia or Unresponsiveness to
coagulopathy resuscitation
It has also been suggested that patients at risk of
adverse outcome, such as those with head injury,
bilateral lung contusions, multiple long bone inju- base abnormalities [11] and coagulopathy, the num-
ries, coagulopathy, hypothermia, or estimated ber of pBRCs administered and the injury severity
operation time of >6 h, should be considered for score have been proven to be of value.
sequential staged surgical ­management [9] (Table Therefore, the decision-making according to
10.2). Markers of the adequacy of shock reversal, the ‘four pathophysiological cascades of poly-
such as serum lactate, are measured routinely in trauma’ appears to be valuable. The parameters
trauma centres. It is therefore easy to envisage the of these four cascades to be remembered could be
routine use of markers of pro- and anti-inflamma- summarized in the following phrase:
tory ­systems such as IL-6, IL-10 and procalcitonin Soft tissue injuries (major extremity fractures,
to aid in the decision to carry out damage control severe pelvic fractures, spinal injuries especially
surgery. Delaying definitive surgery until the shock with spinal cord injury, organ injuries such as
state is fully reversed would appear to be not only head injuries AIS>2 or lung contusions AIS>2),
coagulopathy (platelets <90,000) and shock (sys-
beneficial but imperative [12]. tolic BP<90 mmHg, requirement of vasopres-
The Polytrauma Grading Score (PTGS) [9] has sors) contribute to hypothermia (core temp.
reconfirmed that multiple parameters are important, <33 °C) and systemic inflammation, and are dan-
and even in a prospective database analysis, acid- gerous. [5]
10  Orthopaedic Surgery Approach to Damage Control: Decision-Making and Indications 109

Ich verstehen das mit dem soft tissue injury nicht, To reduce the surgical burden, an unreamed
Organverletzungen wie Leber oder Head sind nail may be considered for the femur if possible,
doch auch grosse Risikofaktoren? and the surgeon should be alert to the possibility
of having to convert to the damage control path-
way at any time throughout the procedure if the
10.2 S
 teps of Decision-Making: clinical condition of the patient deteriorates,
Safe Definitive Surgery called ‘bail-out’ procedure.
Concept to Include Damage Treatment in unstable patients has evolved to
Control and Early utilize a ‘damage control’ approach as preemp-
Definitive Care tive intervention. This entails rapid life-saving
surgery only as absolutely necessitated and
After the initial assessment is completed using timely transfer to the intensive care unit for fur-
ATLS principles, the treating physician usually ther stabilization and monitoring. Temporary sta-
gets a fairly good impression about whether the bilization of fractures using external fixation,
patient is at risk for acute haemorrhage that may haemorrhage control and exteriorisation of gas-
lead to lethal outcome [11]. trointestinal injuries where possible is advocated.
The safe definitive surgery concept encom- Complex reconstructive procedures should be
passes both components from early definitive delayed until stability is achieved and the acute
surgery and damage control since the clinical immunoinflammatory response to injury has sub-
scenario can change rapidly that may require a sided. This rationale is intended to reduce in
change in the management [12, 13]. magnitude the ‘second hit’ of operative interven-
These stages apply for the surgical approach. tion or at least delay it until the patient is physi-
It is understood that nonsurgical causes of insta- ologically equipped to cope.
bility have to be addressed in a parallel fashion:
these usually imply issues of coagulopathy, Conclusion
hypothermia or any combination of the four path- Decision-making should be performed rapidly
ological cascades. and may be subject to revision before, during
The patient’s condition may range from clini- or after the first surgical phase. Some trigger
cally stable to a state named ‘in extremis’, where factors are known that require damage control
there is imminent danger of death. Fortunately, or abbreviated surgeries. Among these are
the majority of patients belongs to the group clas- severe head and chest trauma, multiple frac-
sified as ‘stable’ or to the ‘borderline’ patient tures if the patient is unstable, or uncontrolla-
group (grade I or II (if stable after resuscitation)) ble exsanguination due to severe abdominal or
that can be safely stabilized during the course of pelvic trauma. Damage control orthopaedics
the emergency treatment. is recommended for an unstable patient or a
Stable patients have the physiological reserve patient in extremis, and it has some utility for
to withstand prolonged operative intervention the borderline patient as well. Specific injury
where this is appropriate and can be managed combinations for which damage control ortho-
using an early total care approach, with recon- paedics should be considered are femoral
struction of complex injuries. fractures, if bilateral, pelvic ring injuries with
For the borderline patient, primary stabiliza- profound haemorrhage and multiple injuries
tion strategies may be used but should be under- in elderly patients.
taken with caution and forethought given to This process of decision-making may be
operative strategy should the patient require a defined as ‘injury patient tailored’ for damage
rapid change of treatment rationale. Additional control orthopaedics, e.g. safe definitive sur-
invasive monitoring should be instituted and gery. Regarding this strategy, it continues to
provision made for intensive care unit be essential to validate prognostic criteria, as
admission. achieved in the Polytrauma Grading Score.
110 M. Keel and H.-C. Pape

Further studies should be fulfilled to better 5. Kaplan LJ, Frangos S. Clinical review: acid-base
understand the role of damage control ortho- abnormalities in the intensive care unit – part II. Crit
Care. 2005;9:198–203.
paedics in the treatment of patients that sus- 6. Keel M, Labler L, Trentz O. Damage control in
tained a combination of orthopaedic trauma severely injured patients. Why, when, and how. Eur
and concomitant injuries to the chest and J Trauma. 2005;31:212–21.
head. 7. Keel M, Trentz O. Acute management of pelvic ring
fractures. Curr Orthop. 2005;19:334–44.
8. O’Boynick CP, Kurd MF, Darden 2nd BV, Vaccaro
AR, Fehlings MG. Timing of surgery in thoracolum-
References bar trauma: is early intervention safe? Neurosurg
Focus. 2014;37(1):E7.
1. Pape HC, Lefering R, Butcher N, Peitzman A, Leenen 9. Keel M, Trentz O. Pathophysiology of polytrauma.
L, Marzi I, Lichte P, Josten C, Bouillon B, Schmucker Injury. 2005;36:691–709.
U, Stahel P, Giannoudis P, Balogh Z. The definition of 10. Pape H-C, Remmers D, Rice J, Ebisch M, Krettek C,
polytrauma revisited: an international consensus pro- Tscherne H. Appraisal of early evaluation of blunt
cess and proposal of the new ‘Berlin definition’. chest trauma: development of a standardized scoring
J Trauma Acute Care Surg. 2014;77(5):780–6. system for initial clinical decision making. J Trauma.
2. Hildebrand F, Giannoudis PV, van Griensven M, 2000;49(3):496–504.
Chawda M, Pape HC. Pathophysiologic changes and 11. Pape H-C, Regel G, Tscherne H. Controversies

effects of hypothermia on outcome in elective surgery regarding early musculoskeletal management in the
and trauma patients. Am J Surg. 2004;187(3): multiple trauma patient. Curr Opin Crit Care.
363–71. 1996;2:295–303.
3. Pape HC, Andruszkow H, Pfeifer R, Hildebrand 12. Pape HC, Pfeifer R. Safe definitive orthopaedic sur-
F. Options and hazards to use the early appropriate gery (SDS): repeated assessment for tapered applica-
care protocol in trauma patients with major fractures. tion of early definitive care and damage control?: an
Injury. 2016;47:787. inclusive view of recent advances in polytrauma man-
4. Moviat M, Terpstra AM, Ruitenbeek W, Kluijtmans agement. Injury. 2015;46(1):1–3.
LA, Pickkers P, van der Hoeven JG. Contribution of 13. Tscherne H, Regel G, Pape H-C, Pohlemann T,

various metabolites to the “unmeasured” anions in Krettek C. Internal fixation of multiple fractures in
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 General Surgery Approach to DC:
Decision Making and Indications
11
Molly Deane and Jose J. Diaz Jr

11.1 Introduction This is followed by a period of time for resuscita-

tion and restoring physiologic reserve. Patient
The process by which to select the appropriate selection comes from recognizing the severity of
patients to undergo damage control surgery is the the mechanism of injury, the complexity of the
fundamental beginning to decision making. injury pattern, and/or the presence of physiologic
Classically, the indications to truncate an opera- derangements in light of recognized patient
tion rather than proceed with primary definitive comorbidities. It is usually a combination of mul-
surgical care are acidosis, hypothermia, and coag- tiple factors that end up necessitating the use of
ulopathy (the so-called lethal triad) [1]. Rotondo damage control surgery. The surgeon’s attention
and colleagues coined the term “damage control” to subtle clinical findings at the index operation
laparotomy for exsanguinating penetrating inju- may be the first sign a patient would benefit from
ries (with transfusion of greater than 10 units the damage control approach. Noting that the
packed red blood cells) where a survival benefit patient feels cold, that there is no presence of clot
was noted for a subset of maximally injured in the surgical field, or that the bowels are becom-
patients, those with major vascular and two or ing boggy and edematous are key intraoperative
more visceral injuries [2]. The process of damage findings.
control surgery is divided into phases. The surgeon It should be noted that overuse of damage
must maneuver the patient through these phases ­control exposes patients to the risks of multiple
and constantly reevaluate the ­overall status. operations, open abdomen management, and pro-
longed intensive care stay thereby negating the
potential benefit of the concept [3]. It is estimated
11.2 Indications that fewer than 30% of civilian trauma laparoto-
mies benefit from the damage control approach
In the severely injured patient, time is of the [3]. Its overuse has been demonstrated to cause
essence, and the primary goals of damage control potential harm and can result in long-term mor-
are to control hemorrhage and stop c­ ontamination. bidity [4]. The most frequent complications fol-
lowing an open abdomen include gastrointestinal
fistulas, intra-abdominal abscesses, and ventral
M. Deane, MD hernias [5]. Careful identification of the appropri-
J.J. Diaz Jr, MD, CNS, FACS, FCCM (*)
ate patient and refraining from the overuse of
R Adams Cowley Shock Trauma Center, University
of Maryland Medical Center, Baltimore, MD, USA damage control surgery can avoid unnecessary
e-mail: jdiaz@umm.edu complication.

© Springer International Publishing AG 2017 111

H.-C. Pape et al. (eds.), Damage Control Management in the Polytrauma Patient,
DOI 10.1007/978-3-319-52429-0_11
112 M. Deane and J.J. Diaz Jr

11.3 Patient Factors treat injuries simultaneously. Examples may

include one team performing a laparotomy and
Early recognition of the patient’s existing comor- packing the liver and resecting bowel, while
bidities, prior surgical history, and whether they another team obtains vascular control with a
are taking any anticoagulants or antiplatelet func- shunt in an extremity or places multiple extrem-
tion medications can allow for early selection of ity external fixation devices for complex crush
patients for damage control surgery. In addition, injury associated with fractures. Not only con-
some patients may have low functional reserve sidering that the patient require a damage con-
and benefit from a truncated operation and usher- trol surgery for management of their general
ing to the ICU. surgical injuries, but placing these in context
with the other injuries allows for efficient man-
agement and expedited transition to the ICU for
11.4 Mechanism/Injury Pattern ongoing resuscitation. In these challenging
cases, it is critical for the surgeon to triage the
The type of mechanism of injury can be crucial to critical procedures and involve the appropriate
selection of patients for damage control, and teams.
those selected will typically have blunt poly-­
trauma, multiple penetrating torso trauma, severe
contamination, and major bleeding sources in 11.5 Physiologic Derangements
other regions. These warrant consideration for
damage control surgery as they require prioritiza- Patients are actively resuscitated upon arrival,
tion of injuries and the severity of injury is likely and the process extends into the operating room
to result in the lethal triad. and intensive care unit with the goal of avoiding
Early into the operative case, it is possible to the lethal triad prior to its start to avoid failure of
identify patients who are more likely to benefit correction. Early recognition of any of the fol-
from damage control due to the degree of the lowing should indicate the potential need for
injuries. Patients who require packing of com- damage control surgery [6].
plex liver injury are best served by damage con-
trol. These patients will potentially require Significant bleeding requiring >10 units PRBC
Severe metabolic acidosis pH <7.20
angio-embolization prior to their next operation.
Hypothermia temp <35.0 °C
Patients with multiple bowel injuries such as
Operative time >90 min
combined small bowel and colon injuries with
Coagulopathy as seen by either laboratory result or
segmental resection will require “planned second “nonsurgical” bleeding
look.” These patients may require additional Lactate >5 mmol/L
bowel resection with multiple anastomoses.
Similarly, patients with multiple combined and
complex injuries within the abdomen such as 11.5.1 Decision Making:
gastric and renal or pancreas and spleen will need Considerations at
a damage control laparotomy. Abbreviated con- the Index Operation
trol of multiple complex injuries with packing or
stapling and adequate drainage can be utilized to Trauma patients undergoing laparotomy for trun-
control the abdominal injuries and facilitate sta- cal injuries should be prepped from the chin to
bilization in order to be able to address other both thigh and bilateral posterior axillary lines to
areas of injury. have full access to all body regions and maximize
When considering the mechanism of injury efficiency of the operation.
in a patient with multiple cavity or extremity “Time is of the essence.” Once the decision
injuries, it is important to keep in mind the pos- has been made to proceed with damage control
sibility of involving multiple surgical teams to surgery, the surgeon’s goal should be to complete
11  General Surgery Approach to DC: Decision Making and Indications 113

the initial procedures within 90 min or less. The undergoing damage control surgery typically
clear objectives are (1) to control hemorrhage require a massive transfusion and are at risk for
and (2) stop or control contamination. The abdo- abdominal compartment syndrome. In addition,
men should be left open and a temporary abdomi- rapid return into the abdomen is occasionally
nal closure barrier placed. These patients required.

Damage Control: Decision Making

Trauma bay

Stable Unstable

Trauma OR

Damage Control Surgery

Major MOI Major vascular Massive Packing of Major Multiple small

with multi-cavity Injuries Transfusion Liver Injury and large bowel
&/or long bone requiring Protocol and injuries requiring
fractures temporary concern for resection with
shunt development of questionable
abdominal viability
compartment
syndrome

In addition, it is not uncommon to start a their resuscitation. The importance of packing

trauma laparotomy and find oneself in the midst cannot be underestimated, as it allows for time for
of a very unexpected injury pattern which quickly both the surgical team and the anesthesia team to
goes from bad to worse. What may have started strategize and determine if this is a patient who
out as a semi-elective laparotomy turns into a can now have their injuries formally addressed or
fight for the patient’s survival. Once must be able dealt with in a damage control manner.
to quickly shift gears and move to a “damage While the initial maneuver of hemorrhage
control” mode. control is packing, pattern recognition will guide
the surgeon to the potential source of bleeding. If
the patient remains profoundly hypotensive fol-
11.6 Hemorrhage Control lowing packing, a significant source of arterial
hemorrhage is likely. A well-packed liver injury
The first step in the trauma laparotomy is per- that continues to bleed may have a retrocaval
forming a generous midline incision as it pro- injury. If bleeding is coming from the mid abdo-
vides exposure to all four quadrants in the men after packing of the gutters, bleeding may be
abdomen. The next step is deciding on exposure, coming from the root of the mesentery. If an
commonly a self-retaining surgical retractor enlarging retroperitoneal hematoma is identified
should be ready to place and retract the abdomi- in any of the zones, a surgical bleeding is likely to
nal wall. be encountered. Suspicion of this type of injury
Hemorrhage control initially starts by expos- may require temporary aortic occlusion with
ing the bleeding. This is best done by efficiently either a cross-clamp or intra-aortic balloon both
packing the abdomen with laparotomy pads. This of which require additional areas to be prepped
has the dual effect of “mopping up” and tam- and additional equipment.
ponading the bleeding. This maneuver allows the Major vascular injuries should be initially
anesthesia team time to begin to catch up with controlled with Allis clamps for lateral injuries or
114 M. Deane and J.J. Diaz Jr

cross-clamps for transections. For major arterial injuries can result in delayed ischemia or perfora-
or venous injuries, initial management may be tion, which can threaten anastomoses and sto-
either vessel ligation or the placement of tempo- mas. Knowing the patient will require a “second
rary intravascular shunts in critical arteries [7]. In look” based on the injuries allows a switch to
the context of uncontrolled hemorrhage, the sub- proceeding with damage control and foregoing a
clavian vein, iliac vein, and inferior vena cava longer more definitive operation. Those necessi-
can all be ligated at the risk of development of tating “second look” consist of boggy or edema-
severe limb edema. The external carotid can be tous bowel, dusky with poor perfusion without
ligated without consequence and the internal frank ischemia, and in areas of mesenteric hema-
carotid with the risk of neurologic deficit. tomas without bowel compromise.
Ligation of the femoral artery can result in criti- After resecting affected sections of bowel, the
cal limb ischemia, slightly higher than the risk of next decision point is when to perform the anas-
ligating the subclavian artery, however both can tomosis and in what fashion. With regard to
be shunted [8]. deciding between stapled versus handsewn,
For patients with severe liver injuries, the ini- numerous studies have attempted to evaluate if
tial goal should be control of bleeding, as it is the one is superior to another and have yet to iden-
uncontrollable hemorrhage which is the cause of tify a striking difference [10]; however in diffi-
early death and the related requirement of mas- cult cases with edematous bowel, many surgeons
sive transfusion which contributes to late fatal will tend toward performing a handsewn anasto-
complications [9]. A complex liver injury can be mosis. A potential reason to perform a handsewn
managed with a Pringle maneuver followed by anastomosis is when there is bowel edema. There
supra and infrahepatic packing. The falciform are comments in the literature stating that there
ligament should be divided as not to injure the still may be a difference in outcomes between
liver during packing. Pattern recognition should the two, which has simply failed to be demon-
continue to be appreciated when the packed liver strated by existing literature. It has been reported
packing does not stop bleeding and appears. An that handsewn anastomoses do consume signifi-
arterial injury should be suspected and suture cantly more time and this should be taken into
ligated must be performed if possible. A neces- account [11].
sary consideration is the role of angiography as For colonic injuries, these can be primarily
an adjunct for therapeutic intervention. While repaired or resected and placed back into conti-
another option is going to angio-embolization nuity with an anastomosis. The average leak rate
after packing of a major liver injury, when plan- is 16% and from the largest study 18%. There is
ning on taking a patient with significant abdomi- the suggestion that repair and anastomosis is
nal trauma for operation, placing the patient on a preferable in a patient in whom there is an open
radiographically compatible table or in a hybrid abdomen. The rationale is such that while this is
suite can facilitate performing angiography for a “high-risk” anastomosis, with the abdomen
control of visceral or pelvic hemorrhage after the open, the bowel can be inspected for potential
abdomen has been packed or externally fixated. complications prior to abdominal closure, and
this eliminates the potential morbidity of an
ostomy [12]. Another suggestion is to wait to
11.7 Contamination decide whether to perform an anastomosis versus
ostomy at the second operation after determining
In some circumstances the mechanism of the dif- whether the patient is able to be closed [13]. The
fuse extent of injury can require a “second look” reasoning is that there is an increase in complica-
in order to evaluate the evolution of injuries. In tions including anastomotic leaks when patients
high-energy injuries the extent of bowel wall are not closed within 5 days. All of these factors
injury is often not apparent at the initial opera- address thinking of damage control surgery with
tion, and a second evaluation is crucial as these care of bowel in isolation. This should be taken in
11  General Surgery Approach to DC: Decision Making and Indications 115

the context of potential confounding factors such aged with damage control with an average of
as suspicion of tenuous blood supply or other 1.66 complications per patient [16]. In addition,
associated injuries, such as pancreatic injury, patients closed within 7 days of their index oper-
which may place a repair or anastomosis at addi- ation were found to have less daily pain, higher
tional risk. rate of return to work after injury, and higher
quality of life [17].

11.8 M
 anagement of the Open Conclusions
Abdomen When considering damage control manage-
ment, it is important to continually reassess the
After patients have undergone correction of their patient’s clinical status and prioritize this along
physiologic derangements, they should return to with their injuries to perform focused opera-
surgery for definitive repair. Ideally, this first trip tive interventions with the main goal of resus-
back to the operating room should occur within citation. At each point one must ask whether
36 h. This return to the operating room can be the patient has ongoing physiologic derange-
done in either an on-demand or scheduled fash- ments or are they able to move on to the next
ion; however, on-demand laparotomy is associ- phase. It is important to recognize that this is a
ated with a reduction in re-laparotomies and dynamic process, and at each branch point, the
negative laparotomies and may result in cost sav- patient can return to a state of dysfunction and
ings. In a normothermic patient, they should require ongoing damage control management.
undergo re-laparotomy for ongoing transfusion One approach to conflicting priorities is to
requirement of 2 units of RBC/hour [14]. There is involve multiple teams simultaneously with
the potential that during this first return to the each addressing a separate injury/region in
operating room, they may not be able to achieve order to minimize operative time/stress and
definitive repair of their injuries or the edema is more quickly address hemorrhage and
such that it is not possible to close the abdomen. contamination.
Significant risk of development of abdominal Careful consideration of the long-term out-
compartment syndrome is a contraindication to comes aids in operative management in order
abdominal closure, as is recurrence of physio- to give critically injured patients the highest
logic derangement or ongoing contamination. chance of the best possible outcome given
The concept remains that there must be a con- their particular circumstance and injuries. The
tinual reevaluation of the status of the patient and goal is to do what is vitally necessary up front,
their injuries in order to determine whether or not move to the ICU for resuscitation, then stage
the patient is ready to undergo their definitive sur- the definitive repairs. Minimizing the number
gical therapy. When evaluating which patients of patients selected for damage control to only
were unlikely to achieve primary fascial closure those necessary and then minimizing the num-
during their initial hospitalization, it is patients who ber of interventions, time to anastomosis, and
had higher numbers of explorations and developed time to closure have improved outcomes.
intra-abdominal abscess/sepsis and blood stream
infections and those who develop acute renal fail-
ure or enteric fistulas and ISS >15 [15]. References
As soon as physiologically possible, patients
do better with abdominal closure. In keeping this 1. Stone HH, Strom PR, Mullins RJ. Management of the
in mind, it is possible to reduce the morbidity major coagulopathy with onset during laparotomy.
Ann Surg. 1983;197:532–5.
associated with damage control laparotomy. For 2. Rotondo MF, Schwab CW, McGonigal MD, et al.
patients closed at first take back, the overall com- ‘Damage Control’: an approach for improved survival
plication rate was reduced to 47%, significantly in exsanguinating penetrating abdominal injury.
lower than the reported 63% for all patients man- J Trauma. 1993;35:375–82.
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3. Waibel BH, Rotondo MM. Damage control surgery: s­ystematic reviews and panoramic meta-analysis:
its evolution over the last 20 years. Rev Col Bras Cir. staples versus sutures for surgical procedures. PLoS
2012;39:314–21. One. 2013;8:e75132.
4. Higa G, Friese R, O’Keeffe T, Wynne J, Bowlby P, 12. Kashuk JL, Cothren C, Moore EE, Johnson JL, Biffl
Ziemba M, et al. Damage control laparotomy: a vital WL, Barnett CC. Primary repair of civilian colon inju-
tool once overused. J Trauma. 2010;69:53–9. ries is safe in the damage control scenario. Surgery.
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damage control and predict outcome. Am J Surg. Badonas R, Bilaniuk JW, Bilaniuk JO, Collier BR,
2001;182:743–51. Como JJ, Cumming J, Griffen M, Gunter OL, Kirby J,
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 New Technologies for Vascular
Injuries and Hemorrhage Control
12
Megan L. Brenner and Thomas M. Scalea

12.1 Introduction Obtaining proximal control of the aorta at the

diaphragm is a standard maneuver to reduce intra-
The rapid control of hemorrhage is at the corner- abdominal blood loss. It requires a laparotomy or,
stone of all injury care. In most cases, direct surgi- in some cases, entering the left chest. The standard
cal exploration and control of hemorrhage suffices intraoperative techniques of inflow control within
even with large volume blood loss. However, the abdomen include direct clamping, manual
some new advances have given us additional tools compression, sponge-stick compression, and the
that can be quite helpful in selected cases. Binders archaic “aortic occlude.” Transfemoral balloon
can reduce the bony elements of the pelvis, reduc- occlusion of the aorta has been utilized for decades
ing pelvic fracture hemorrhage. A number of in cases of exsanguinating hemorrhage below the
commercially available hemostatic agents pro- diaphragm for numerous non-­trauma conditions.
vide direct pressure onto blood vessels and pro- Recently, the technique has been adapted for use
mote clotting. Newer resuscitation strategies in trauma patients and is currently performed by
stress the use of plasma and platelets early. This acute care surgeons in the USA. Patients who may
balanced resuscitation likely prevents the coagu- benefit from this include those in shock with intra-
lopathy of trauma instead of treating it. abdominal or pelvic bleeding.
In addition, endovascular techniques have It is mandatory that surgeons interested in the
revolutionized care for badly injured patients. care of badly injured patients “lead the charge” in
Angiography allows for precise definition of these new areas. While other disciplines certainly
bleeding arteries without surgical exploration. have advanced skills and much too often in areas
This minimally invasive technique does not risk such as endovascular techniques, only the surgeons
the disruption of the existing hematoma and does understand the care of the entire patient. Regardless
not increase the blood loss or heat loss associated of how care is organized in an individual center, the
with open surgical procedures. In order to be trauma surgeon must remain “captain of the ship.”
effective, all components of this resource must be Patient selection is key to the successful utilization
immediately available at all times. of these innovative techniques, again stressing that
trauma surgeons need to be involved. It is impera-
tive to serially assess patient stability and change
course if the patient’s status changes. These patients
M.L. Brenner, MD (*) • T.M. Scalea, MD
are u­ sually quite dynamic, and it requires minute-
Shock Trauma Center, University of Maryland,
Baltimore, MD, USA to-­
minute and even second-to-second decision-
e-mail: mbrenner@umm.edu making to utilize these innovative strategies safely.

© Springer International Publishing AG 2017 117

H.-C. Pape et al. (eds.), Damage Control Management in the Polytrauma Patient,
DOI 10.1007/978-3-319-52429-0_12
118 M.L. Brenner and T.M. Scalea

Fig. 12.1 Hybrid operat-

ing room at RA Cowley
Shock Trauma Center

12.1.1 Endovascular Damage Control were difficult to approach surgically, such as

bleeding deep in the right lobe of the liver or in
Damage control, described in 1993, represented a the pelvis.
paradigm shift in trauma care using damage con- As damage control has evolved and access
trol. All operative care was no longer accom- and expertise to endovascular techniques have
plished at the time of presentation. Instead, only increased, the use of endovascular hemostasis as
life-threatening hemorrhage was addressed at the part of damage control has become more fre-
index operation. Nonsurgical hemorrhage was quent. These endovascular techniques are now
controlled with temporary hemostatic packing, sometimes used as definitive therapy with opera-
gastrointestinal contamination temporarily con- tive care, but still are often used in combination
trolled, and the abdomen left open. The patient with operative hemostasis. The advent of hybrid
was then brought to the intensive care unit. After operating rooms has greatly increased the num-
physiologic stabilization, the patient is returned ber of possibilities. These novel ORs now allow
to the operating room for completion of defini- all care to be delivered in a single location, elimi-
tive care. nating the need for multiple transfers (Fig. 12.1).
Initially, damage control was accomplished
with direct surgical maneuvers only. However, it 12.1.1.1 Angiography
soon became clear that endovascular procedures and Embolization
could serve as a valuable adjunct to a traditional The management of pelvic and renal hemorrhage
surgical approach. Angiographic embolization, using catheter-based techniques was published in
which was then being introduced for trauma small numbers almost 50 years ago [1, 2]. Shortly
hemostasis all over the body, became part of thereafter, the first report of intercostal injury con-
damage control. Typically, patients underwent trolled by embolization was published in 1977
their initial surgical procedure and were immedi- [3]. Angiography for pelvic fractures was first
ately taken to the angiography suite for catheter described in 1972. Later case reports suggested
hemostasis. As experience accumulated, trauma angioembolization alone or in combination with
practitioners recognized catheter hemostasis as a surgical therapy for highly lethal pelvic hemor-
powerful tool to control hemorrhage in areas that rhage was both feasible and effective [4–6]. At the
12  New Technologies for Vascular Injuries and Hemorrhage Control 119

same time, the group at Kings County Hospital in competence over time as these procedures are
Brooklyn pioneered endovascular therapy for used relatively rarely, even in busy centers.
trauma and reported good outcomes in several Interventionalists in Japan, where acute care
series treating both splenic and pelvic hemor- surgeons are not as readily available as in other
rhage [7–9]. Endovascular control of hemorrhage countries, have extended the use of catheter-­
became routine. Roudsari et al. recently reported based hemorrhage in the treatment of severe solid
the use of angioembolization for pelvic and liver organ and pelvic injuries, including hemodynam-
injuries increased from 30–50% in 1996 to 100% ically unstable patients [14–16]. In Japan, where
in 2010 at a designated level 1 trauma center [10]. waiting for a surgeon may not always be feasible,
Early on, operative exploration was thought to by virtue of necessity, trauma practitioners have
be necessary for all abdominal injuries. Early heavily adopted interventional methods with suc-
diagnostics like physical exam and diagnostic cess using a technique they have termed damage
peritoneal lavage could identify patients with control interventional radiology (DCIR), a non-
injuries, but could not identify the injured organ operative technique analogous to damage control
or the severity of the organ. CT scanning allowed surgery in poly-injured patients. In Japan, these
for organ-specific diagnosis and preoperative interventionalists utilize “prompt and rapid endo-
injury grading and allowed clinicians to manage vascular strategies in trauma occasions”
some injuries without surgery. Catheter hemosta- (PRESTO), referring to the aggressive and time-­
sis then became attractive as an adjunct to obser- conscious use of endovascular therapy in trauma.
vation. Patients with isolated solid organ injury They have adapted their environment to be able
could be managed without the need for open to use this safely. The admission area in these
exploration. When effective, this reduced mor- facilities has the ability to perform X-ray, CT,
bidity and hospital length of stay. Soon, patients fluoroscopy, and resuscitation in the same room
with multiple injuries such as a liver and splenic [17]. Because some admitting emergency physi-
injury started to be managed with catheter hemo- cians are also trained interventionalists, the usual
stasis alone. At that time, patients had to be stable hurdles to rapid angioembolization are essen-
to use these techniques. tially nonexistent.
Perhaps the greatest limitation in the use of Angiography may also be used for diagnostic
angioembolization is universal availability. Even purposes, particularly in the multi-trauma patient
at major trauma centers with advanced capabili- whose body habitus or hemodynamic instability
ties, there often are discrepancies in availability prevents travel to the CT scanner. Injuries identi-
of this adjunct during hours of peak trauma fied with diagnostic angiography can be treated at
intake, nights and weekends [11]. One novel the same time. This includes endovascular con-
solution being explored is to expand the skillset trol of splenic, hepatic, pelvic, carotid, lumbar,
of initial trauma responders, who are most com- and intercostal artery injuries. Technology has
monly present at the bedside when victims of sig- advanced from simple nitinol coils to Gelfoam
nificant injury arrive, often in the middle of the and plug devices which can be used to rapidly
night and on weekends [12]. Certainly, basic stop hemorrhage in these locations. N-Butyl
endovascular skills, such as the emergent place- ­cyanoacrylate (NBCA) is used with success as it
ment of transfemoral balloons, should be in the acts quickly and permanently occludes vessels
armamentarium of the acute care surgeons who [18, 19], as opposed to some agents such as
routinely insert large-bore lines percutaneously. Gelfoam “slurries,” coils, or plugs, which can
However, additional expertise as needed can be sometimes take many minutes to provide com-
gained in well-designed courses [13]. Additional plete occlusion. This makes endovascular tech-
study is required to determine the extent of train- niques attractive, even in patients with substantial
ing required to safely incorporate more advanced ongoing hemorrhage.
skills such as embolization into the skillset of the The appropriate level of angioembolization can
trauma/acute care surgeon and how to maintain be controversial. Embolization at the level of an
120 M.L. Brenner and T.M. Scalea

origin artery can be accomplished quickly and, in hemostasis in patients with high-grade liver inju-
many vascular beds, effectively controls bleeding. ries. In such cases, patients are typically in shock
However, continued bleeding via collateral circula- and are explored initially. Large vessel bleeding is
tion can occur. The regional sparing of organ tissue controlled surgically. However, injured vessels
that can be achieved with more distal “selective” or deep in the parenchyma, particularly in the right
“super-selective” embolization makes it attractive. lobe, are difficult to approach via laparotomy. In
The complexity and time required that may be these cases, after surgical bleeding is controlled,
associated with achieving this pinpoint hemostasis the liver is packed for temporary hemostasis.
of a bleeding pelvic vessel or solid organ injury site Angiography then identifies these injured blood
must be balanced against concerns for ongoing vessels, and they can be occluded using a variety
bleeding and/or other pressing needs in a multi- of endovascular techniques. The patient can then
injured trauma patient. This is particularly perti- be unpacked and the liver reexamined when the
nent when being used as part of damage control. patient is fully resuscitated.
Defining the optimal approach is challenging, as Hepatic embolization, while effective, can be
the variety of variables that must be considered morbid. Dabbs et al. described a 40% incidence
makes focused study of this issue problematic. of major hepatic necrosis after embolization for
While the use of angioembolization technique liver injuries [24]. This often becomes symptom-
is currently well established, with a proven track atic 2–5 days after embolization. While the
record in the treatment of pelvic and solid organ symptoms are nonspecific, they often include
bleeding after injury [15, 16, 20–23], patient elevations in liver function test, leukocytosis, and
selection continues to be an active area of discus- fever. CT scan shows air in areas of nonviable
sion. Patient physiology plays a significant role liver. While several treatment options exist, our
in the utilization at most centers. Associated approach is early hepatic lobectomy, which can
radiographic findings, including significant be accomplished safely [25]. This is simply a
hematoma and active contrast extravasation or more modern application of damage control.
“blush,” also likely guide the wise employment Embolization can also be very effective
of this modality. Despite extensive study on the to arrest pelvic hemorrhage either as a primary
topic, ideal selection criteria remain a matter of modality or combined with extraperitoneal pelvic
disagreement. Several association guidelines packing. Patients often present in profound shock.
have been developed for the management of Extraperitoneal pelvic packing is ­performed via
severe solid organ and pelvic hemorrhage such as either a low midline or Pfannenstiel incision.
the Western Trauma Association, the Eastern Care must be taken to avoid entering into the
Association for the Surgery of Trauma, and the
American Association for the Surgery of Trauma.
Embolization can often be used as definitive
hemostasis. This technique seems ideally suited
for stable patients with high-grade splenic inju-
ries. In such cases, observation may fail between
25% and 50% of the time. Mandatory use of coil
embolization in the proximal splenic artery in
high-grade splenic injuries, regardless of whether
a contrast blush is present, has been shown to
result in splenic salvage over 95% of the time
(Fig. 12.2).
Embolization can also be combined with
­surgery and is an integral part of total patient care
when using damage control techniques. It is Fig. 12.2  Grade 3 splenic injury with pseudoaneurysms
­perhaps most commonly combined with operative requiring proximal splenic artery embolization
12  New Technologies for Vascular Injuries and Hemorrhage Control 121

abdominal cavity as the intact peritoneum is left posterior thoracotomy. The recognition that
essential for effective pelvic packing. Packing repair for these injuries can be deferred safely
can be followed by immediate angiographic using anti-impulse therapy has allowed severely
embolization. The pelvis can then be unpacked injured patients with BTAI to be treated using
and closed relatively early. damage control principles, as these injuries no lon-
Angiographic embolization is also effective ger require emergency care. Thus, patients can be
deep in the retroperitoneum following laparot- stabilized in the ICU and the aortic injury treated
omy for penetrating injury. The patient is gener- with a minimally invasive approach 1–2 days later.
ally explored first and injuries within the abdomen The advent of thoracic endovascular aortic
controlled. Controlling vessels deep in the pelvis, repair (TEVAR) utilizing endovascular stent
particularly in the hypogastric distribution, can grafts as definitive therapy has resulted in both
be extremely difficult. Likewise, controlling dis- improved morbidity and mortality among patients
tal branches of the lumbar arteries can be diffi- who survive to reach care after BTAI. Although
cult. In these cases, the patient can be packed and appropriate patient selection remains paramount
those blood vessels visualized with angiography to success, the clear success of TEVAR has dra-
and occluded with embolization. matically altered the standard of care for BTAI
While endovascular damage control is most patients throughout the world.
often used on the abdomen, it can be helpful in In their landmark 2008 report, Demetriades and
the chest as well. Direct surgical control of proxi- colleagues of the AAST BTAI study group [26]
mal intercostal arteries can be difficult. The nar- documented significant improvements in BTAI care
row angle between the ribs and the spine makes associated with the transition from open to endovas-
exposing and controlling bleeding from the inter- cular repair. In 193 patients with BTAI, TEVAR
costal vessels in that location problematic. This is was associated with significantly decreased transfu-
particularly true in the lower intercostal arteries, sion requirements and lower mortality compared to
which are located deep in the sulcus behind the open repair. A more recent multi-institutional study
diaphragm. When these are discovered at the is consistent in these original findings demonstrat-
time of chest exploration, they can be temporar- ing a significantly lower PRBC requirement (mean
ily controlled with packing and then definitively 5.9 vs. 3.1 units, p < 0.002) in the first 24 h and a
controlled with angiographic embolization. lower overall mortality (8.6% vs. 19.7%, p = 0.021)
and aortic-­ related mortality (13.1% vs. 2.5%,
p = 0.003) among patients treated with TEVAR
12.1.2 Stent Grafting compared to open repair [27].
The 2008 report of the AAST BTAI study
Endovascular stent grafting as damage control can group demonstrated a significant rate of
also be used as definitive therapy or even as a bridge ­TEVAR-­related complications [26], as 18.4%
to open repair. Stent grafts may be used temporarily patients had some form of stent graft-specific
or permanently to cover partial- or full-thickness complication, most notably endoleak in 13.6%.
injuries, particularly in major vascular injury that The continued advancement of endovascular
cannot be easily or rapidly accessed with surgical technologies since this report, including stents
exposure. Placing a stent across a full-thickness specific for aortic trauma, as well as operator
injury may be extremely helpful in the physiologi- experience, has decreased these adverse events
cally devastated patient by rapidly decreasing blood following TEVAR [28] (Fig. 12.3). Paralysis,
loss and preventing coagulopathy. stroke, and left upper extremity ischemia with
The signature application of endovascular stent left subclavian artery coverage have significantly
grafts is perhaps their use in the treatment of blunt decreased over time [29–32], and grading
thoracic aortic injury (BTAI). In the past, standard ­systems to help delineate suitability for endovas-
therapy for any patient with a diagnosed BTAI cular versus open approach as well as nonopera-
involved an emergent open treatment, usually via tive management have evolved [33–35].
122 M.L. Brenner and T.M. Scalea

Fig. 12.3 Grade 3 blunt

a b
thoracic aortic injury
treated with stent graft

The success of TEVAR for BTAI has paved outcomes over historical controls [37]. As stent
the way for collaborative efforts between trauma grafting is likely much quicker than a difficult
surgeons and endovascular providers in explor- open repair, this becomes attractive as part of
ing other anatomical sites where endovascular damage control.
stent grafts may provide more ideal solutions The vast majority of patients with free aortic
than more traditional means of open vascular rupture die at the scene. Most that survive to
control and repair. In one recent study by Branco reach the hospital have ruptures that are at least
and colleagues [36], investigators reviewed the partially contained. In poly-traumatized patients,
recorded rate of endovascular stent graft use other injuries are often more immediately life-­
among trauma patients from the American threatening. In those patients, repair of the aorta
College of Surgeons National Trauma Databank. must be deferred as they require operative ther-
These researchers found that, compared to the apy for life-threatening injuries in the cranium,
0.3% rate of utilization in 2002, there was a sig- abdomen, or pelvis. Some may even be too unsta-
nificant increase in endovascular technology uti- ble to have imaging preoperatively.
lization for trauma by 2010 (to 9.0%, p < 0.001). In those cases, the diagnosis of BTAI can be
The most dramatic changes in utilization occurred made by intraoperative TEE. As the patient stabi-
among injured vessels located at sites associated lizes, the aortic injury can be temporized by the
with anatomically challenging exposures – use of anti-impulse therapy. The patient can then
including iliac and axillo-subclavian locations. have their BTAI stented, ideally before they leave
When outcomes were compared between the operating room.
matched patients who underwent endovascular
and open procedures, patients undergoing endo-
vascular procedures had significantly lower in-­ 12.1.3 Resuscitative Endovascular
hospital mortality (12.9% vs. 22.4%, p < 0.001) Balloon Occlusion of the Aorta
and decreased rates of sepsis after intervention (REBOA)
(7.5% vs. 5.4%, p = 0.025). A variety of similar
investigations have demonstrated similar find- The most common cause of each death after
ings reflective of increased utilization of endo- trauma remains hemorrhagic shock which can be
vascular approaches to hemorrhage control and compounded by ongoing coagulopathy. Early
blood vessel injury – associated with improved proximal control of the aorta can be a lifesaving
12  New Technologies for Vascular Injuries and Hemorrhage Control 123

maneuver by reducing ongoing bleeding until the and inflated at the distal abdominal aorta
injury can be approached. An intra-aortic occlu- (Zone 3) (Fig. 12.5). Contraindications for
sive balloon placed through an open approach was REBOA include suspected major cardiac, pul-
first described for controlling major aortic hemor- monary, or vascular injury above the diaphragm.
rhage in the Korean War [38]. Reports of use for
control of bleeding during pelvic surgery [39, 40],
hepatobiliary surgery [41], orthopedic surgery
[42], postpartum hemorrhage [43], and repair of
ruptured AAA [44–46] strongly support the use of
the REBOA in serious intra-abdominal and/or ret-
roperitoneal bleeding. Physiologic parameters
such as serum lactate, pH, pCO2, and central,
cerebral, and coronary perfusion in animal models
of hemorrhagic shock have been shown to improve
with REBOA use [47–50]. Early descriptions of
its use for trauma were rare [51, 52] until recently,
but as experience increased, indications began to
include control of noncompressible torso hemor-
rhage after trauma in the abdomen and pelvis.
The use of REBOA to obtain proximal control
at the level of the diaphragm prior to entering the Fig. 12.4  ER-REBOA balloon occlusion in Zone 1
abdomen may have a role in early control of trau-
matic intra-abdominal hemorrhage. Currently,
indications for REBOA include persistent hypo-
tension with hemorrhage below the diaphragm,
including severe pelvic hemorrhage. Patients
with abdominal injury, which arrive in extremis
or in cardiac arrest, have traditionally been
treated with left thoracotomy for aortic control
and to facilitate open cardiac massage. However,
in patients arriving in arrest from blunt mecha-
nisms without evidence of severe great vessel
injury, ED thoracotomy with open cardiac mas-
sage has been largely replaced in some centers by
REBOA with closed chest compression, particu-
larly in light of data suggesting that open chest
compressions and closed chest compressions
result in similar EtCO2 [53].
The appropriate location of balloon place-
ment and inflation is determined by source of
hemorrhage. The initial evaluation process,
including chest and pelvic X-rays and FAST
Fig. 12.5  ER-REBOA (Prytime Medical Inc.) balloon
exam, helps localize potential site(s) of hemor- occlusion in Zone 3. The device was inserted in Zone 1 in
rhage. For intra-abdominal hemorrhage, the bal- the resuscitation area for severe intra-abdominal and pel-
loon is inserted and inflated at the level of the vic hemorrhage, and the patient was taken to the hybrid
OR for abdominal exploration and packing followed by
diaphragm (Zone 1) (Fig. 12.4), while for pelvic
angioembolization of the left hypogastric artery. The bal-
hemorrhage with a negative chest X-ray and loon was deflated and repositioned in Zone 3 after abdom-
abdominal FAST exam, the balloon is inserted inal exploration, hemostasis, and packing
124 M.L. Brenner and T.M. Scalea

Placement can be ­performed in the resuscitation Access complications can be potentially limb-­
area using portable or digital X-ray or in the threatening, and a small case series in Japan
operating room under fluoroscopy. An immedi- describes a limb loss of 21% [56]. It is unclear
ate increase in SBP should occur if the tech- whether the irreversible extremity ischemia in
nique is successful. these patients was related to the procedure, initial
Several case reports and case series have doc- injury, or both. These studies describe the experi-
umented significant increases in systolic blood ence with REBOA abroad; thus, it is not known
pressure with REBOA [14, 54, 55]. Transportation whether these results can be applied in the USA
to definitive treatment, or first to the CT scanner where different technologies, protocols, indica-
(Fig. 12.6), can then occur with the REBOA in tions, and providers’ experiences and skills may
place and the balloon inflated. The duration of apply.
aortic occlusion that can be safely tolerated var- Our earliest experience with REBOA in two
ies considerably and may be impacted by patient high-volume trauma centers demonstrates
physiology. Recent evidence suggests that REBOA to be a potentially lifesaving technique
patients may survive Zone 1 occlusion for up to [55]. The devices used were standard “off-the-­
150 min [14], and our clinical experience sug- shelf” aortic occlusion balloons used for years
gests the REBOA can be left inflated safely even by vascular surgeons to temporize hemorrhage
longer in Zone 3. Concern for visceral and from ruptured abdominal aneurysms. The pro-
extremity ischemia is warranted. As clear guide- cedure was modified for use in the resuscitation
lines for this do not exist, the current recommen- area using portable X-ray for device confirma-
dation is to deflate and remove the devices as tion and taught to ACS in a 1-day formal train-
rapidly as possible. ing course. In this series, REBOA was
performed rapidly by those ACS with no proce-
dure-related complications and no deaths from
hemorrhage.
A later and more comprehensive series from the
same two institutions compared REBOA to ED
thoracotomy (EDT) [57]. Survival and other out-
comes were improved in the REBOA group,
patients were less likely to die in the ED with
REBOA, and death from hemorrhage only occurred
in patients who were treated with EDT. The
18-month span of the study demonstrated a clear
paradigm shift in treatment of patients arriving in
arrest, with more REBOAs rather than EDT per-
formed for the same indication. Most importantly,
the study demonstrated no access complications,
limb ischemia, or amputations.
Data from the American Association for
Surgery in Trauma (AAST) Aortic Occlusion for
Resuscitation in Trauma and Acute Care Surgery
(AORTA) demonstrated no difference in aortic
occlusion times between EDT and REBOA, no
difference in survival, and no groin access or
limb ischemia complications [58]. Arterial access
Fig. 12.6  ER-REBOA balloon occlusion in Zone 3.
is emerging as a rate-limiting step of REBOA:
Contrast is visualized in the common femoral arteries due
to collateral circulation, and the 7 French sheath visual- open groin cutdown is required in 50% of cases.
ized in the right common femoral artery Data from our institution also suggests that time
12  New Technologies for Vascular Injuries and Hemorrhage Control 125

to aortic occlusion with REBOA is faster than 12.1.3.2 R  EBOA in the ED and
with EDT only in cases where rapid percutane- Pre-­hospital Environments
ous cannulation is achieved [59]. Improvements The use of REBOA in the pre-hospital environ-
in technology will undoubtedly decrease time to ment is occurring in the United Kingdom [61]
aortic occlusion as users become more experi- and Japan [62]. Emergency physicians and med-
enced and proficient at CFA access and REBOA ics as part of highly skilled mobile units are per-
placement. Recently, a new REBOA balloon forming the procedure on the roadside for patients
catheter compatible with a seven-French intro- in extremis from noncompressible torso hemor-
ducer sheath has been FDA-approved rhage. REBOA may also have a role in the pre-­
(ER-REBOA, Prytime Medical Inc., San Antonio, hospital setting particularly in military or austere
TX). Arguably, this smaller size sheath may environments where delay of definitive hemosta-
result in fewer access site complications. sis is unavoidable. Significant impediments to
REBOA can potentially revolutionize care early use of REBOA include choosing the appro-
when using damage control by rapidly control- priate candidate and cannulating the common
ling bleeding. Surgeons could potentially then femoral artery (CFA). The former is even more
safely spend more time providing definitive challenging without traditional means of initial
care during the index operation. In addition, trauma evaluation such as abdominal ultrasound
the hemodynamic stability gained by the use of and pelvic X-rays. The latter is dependent on a
REBOA may allow the use of an expanded set variety of patient factors and notably the skillset
of endovascular hemostatic options for hemor- of the provider, which must include the ability to
rhage control, particularly within difficult cut down on the CFA when percutaneous cannu-
areas to access surgically. One could easily lation is not possible, which currently occurs
envision a patient with a high-grade liver about half the time [58]. Regardless of the size of
injury being treated with REBOA as a bridge to introducer sheath, access will remain a barrier to
definitive therapy with embolization, as rapid aortic occlusion in those patients where
opposed to an initial laparotomy followed by percutaneous access is not quickly attainable.
embolization. Prerequisite training for REBOA should include
acquisition of ultrasound-guided cannulation
12.1.3.1 Training and Credentialing skills if this is not within a provider’s skillset.
Privileges to perform REBOA are institution-­
dependent but, in our opinion, at minimum 12.1.3.3 Hybrid Trauma OR
should require completion of a formal training A trauma hybrid operating and angiography suite
course unless endovascular skills have previ- expands the options for innovate care and can
ously been acquired. For ACS who have basic supplement traditional damage control technol-
wire and catheter skills, REBOA requires a few ogy. The table must perform fluoroscopy and all
more steps beyond simple arterial or venous needed equipment, devices, and experienced staff
line placement. These additional skills can be must be available within minutes. The hybrid OR
learned by brief, focused training [13, 60]. should ideally be located only a few feet from the
Gaining these skills has translated to safe and trauma admitting area. This allows the team to
effective performance of REBOA in the clini- perform multiple procedures almost simultane-
cal setting [55, 57, 58]. ACS are the only pro- ously – for example, a laparotomy and an extrem-
viders at the bedside initially caring for a ity angiogram – without change in location or
patient who is exsanguinating, making them time delay.
the only real option for these patients, rather A fluoroscopy table, C-arm, monitors, lights,
than waiting for an interventionalist to come and anesthesia, surgical, and endovascular sup-
from other areas of the hospital or outside. plies are the basic materials needed to use the
This is simply too late to use REBOA for most hybrid trauma suite. Additional instruments such
patients. as a TEE, rapid infuser, and intravascular
126 M.L. Brenner and T.M. Scalea

u­ltrasound, as well as cardiopulmonary bypass operating room, the ICU, and the angiography
and dialysis pumps, may be needed. Advancements suite. The hybrid operating room allows all of these
in C-arm technology have led to the production of to happen in a single location when managing a
a CT/C-arm hybrid machine, the Artis Zeego by poly-traumatized patient such as one with a pelvic
Siemens, which combines high-resolution angi- fracture, aortic injury, and severe liver injury.
ography with CT fluoroscopy. This “CT” is not as
sensitive as the 64-slice helical CT but can give
excellent quality three-dimensional views to sup- 12.1.4 Novel Hemostatic Tools
plement two-dimensional angiography. This
allows the team to obtain CT images without New techniques for hemorrhage control continue
travel and additional contrast use and acquire sen- to be developed not only for hospital use but also
sitive information such as endoleaks which can be in the pre-hospital setting. Direct pressure suf-
poorly visualized on angiography. In addition, it fices to temporize hemorrhage from distal
can produce a head CT of adequate quality to rule extremities. This is much more difficult if the
out severe intracranial hemorrhage, particularly bleeding is deep in the extremity or in a location
mass lesions that require evacuation. This may that is difficult to compress. Recent experience
play a role in decisions made in the treatment has demonstrated the potential value of early
algorithm of a multi-trauma patient (Fig. 12.7). tourniquet utilization following extremity injury
The technology for a hybrid OR is costly, in both military and civilian settings [63, 64].
approximately $3–9 million total for the room One problem area that has received focus for
and 1.5–5 million for just the fluoroscopic equip- the military has been “junctional hemorrhage,” or
ment. In addition, the OR staff need to be com- bleeding from sites at the junction of the extrem-
fortable with the acquisition, preparation, use, ity or neck and the torso that are not amenable to
and billing of endovascular devices. A competent traditional extremity tourniquet utilization. In
radiation technologist is essential to help provide order to provide a solution for temporary control
images critical to decision-making and treatment. at these locations, a variety of novel devices have
Radiation safety should be practiced with been developed and studied [65]. One such
vigilance. device, the Combat Ready Clamp (CRoC), has
The use of the hybrid OR extends the use of been shown to provide for effective prolonged
damage control principles. Using damage control control of junctional hemorrhage sites in large
often requires multiple transports between the animal models [66]. The device is presently
approved for utilization in combat settings by the
Department of Defense, but data on human utili-
zation is lacking. Other devices such as the
abdominal tourniquet, SAM junctional tourni-
quet, and Jett tourniquet have been utilized in
military settings with anecdotal success.
Local hemostatic agents can also be quite
helpful when hemorrhage cannot be controlled
by direct pressure alone. These agents are
divided into three categories. Synthetic sealant
agents and agents that work by mechanical
action are considered medical devices.
Hemostatic agents that produce local clotting are
considered drugs [67].
Sealant agents polymerize in an aqueous envi-
Fig. 12.7  CT scan of the head performed in the hybrid ronment producing a mechanical seal. This is
room with the Artis Zeego (Siemens) independent from the coagulation process. These
12  New Technologies for Vascular Injuries and Hemorrhage Control 127

agents are useful in a number of settings, includ- 12.1.4.1 Intra-abdominal Foam

ing sealing vascular anastomoses. Complications Another novel technique for control of noncom-
include systemic embolization, anastomotic ste- pressible hemorrhage that has been proposed has
nosis if used in vascular surgery, and growth been the use of self-expanding foam. This
problems when used in children. polyurethane-­ based expandable agent can be
Agents that work by mechanical action require introduced into the abdominal cavity via a percu-
platelet activation to be useful. These agents cre- taneous delivery system of a patient suffering sig-
ate a three-dimensional structure that allows clot nificant intra-abdominal bleeding. On the
formulation. A number of these agents swell. battlefield, where distance from surgical care may
Intraoperative blood salvage cannot be used be quite large and pre-hospital times extensive,
when using any of these agents, and they may this could be quite helpful. If delivered effectively
become adherent to neurologic structures causing into the abdominal cavity of a bleeding patient,
neuropathic pain and/or neurologic dysfunction. this self-expanding foam can assist in the tampon-
A number of these mechanical action agents ade of bleeding sources and keep an injured sol-
were popularized during recent military conflicts. dier alive until such time as they can be delivered
Several were manufactured utilizing crustacean to a facility capable of providing subsequent lapa-
shells. Unfortunately, the use of these requires rotomy. The foam can then be removed upon
removal which can be difficult. Exothermic reac- entry into the abdominal cavity and the operative
tions which can be severe occur with at least one control of bleeding sources accomplished.
product. In addition, antigenic reactions can Several groups have provided preclinical data
occur. For the most part, these agents are now uti- that support the potential of intra-abdominal
lized only in the pre-hospital setting or the emer- polyurethane foam as an adjunct for pre-hospital
gency department and are applied externally. treatment of abdominal bleeding [68–71]. While
Some trauma centers, however, continue to utilize this animal and cadaver data appears to demon-
these agents internally as part of packing when strate the potential of this adjunct, there has been
using damage control techniques. It is imperative no clinical utilization to date, and this interven-
to remember that these must be removed when the tion has only been proposed for the most austere
patient is reexplored. Some of the manufacturers of military settings. Significant additional study
are now making these agents radiopaque to be is required to define the optimal patient selection
sure they are not inadvertently left in a patient. and utilization of this potential therapy.
Adhesive agents enhance the coagulation cas- Additional agents such as ClotFoam, a fibrin-­
cade, producing a fibrin-rich clot at the site of based hemostatic foam, and XStat, a nonabsorb-
hemorrhage. The composition of these agents able, expandable hemostatic sponge, show
varies most utilizing fibrin with or without fibrin- promise in early investigation through limited
ogen. These agents may be loaded onto a sponge clinical trials.
to facilitate delivery of the hemostatic agent. The
liquid fibrin glues are generally effective when
treating mild hemorrhage or diffuse ooze. The References
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 Part III
Phases of Damage Control
 Prehospital Damage Control
13
Eileen M. Bulger

13.1 R
 ecognition of Hemorrhagic the first 24 h [1]. This paper reviewed five s­ tudies,
Shock one of which was in the prehospital setting and
the others early after hospital arrival. All demon-
Patients who have sustained blunt or penetrating strated a relationship between an increase in
torso trauma are at risk for significant bleeding shock index and the need for transfusion. The pre-
and should be assessed for signs and symptoms hospital study reported that an SI ≥1.0 after at
consistent with hemorrhagic shock. Early signs least 1 l of fluid had a specificity of 90.5% and a
of shock can be very subtle and may include dia- sensitivity of 47.9% for predicting the need for
phoresis, pallor, altered mental status, and tachy- >5u blood in the first 4 h [2].
cardia. While traditional triage rules have focused A limitation of the shock index is that it relies
on a systolic blood pressure of ≤90 mmHg as on normal physiologic response to hemorrhage
evidence of shock, hypotension is generally a late and thus may be impacted by medications such as
sign and suggestive of severe hemorrhage. beta-blockers that will suppress tachycardia. In
addition, elderly patients who have a baseline
hypertension may not manifest as significant a
13.1.1 Shock Index decline in blood pressure as a younger patient.
Some authors have suggested that a systolic blood
Several authors have assessed the utility of using pressure <110 mmHg may be more predictive in
the shock index (SI), which is defined as the ratio an elderly trauma population [3]. One author sug-
of heart rate divided by systolic blood pressure, as gested using Age x SI [4]. When applied to all
a predictor of hemorrhagic shock. A shock index patients, this score did not perform well, but when
≥0.9 after injury has been associated with hemor- restricted to those over age 55 years, the area
rhagic shock. A recent meta-analysis assessed the under the receiver operating curve increased sig-
ability of the SI to predict critical bleeding which nificantly. A recent study from the National
was defined as at least 4 units of red blood cells in Trauma Databank review the relationship between
shock index and outcome for patients over age
65 years [5]. This study demonstrated that patients
E.M. Bulger, MD with an SI ≥1.0 were significantly more likely to
Department of Surgery, require a blood transfusion, require an explor-
University of Washington,
atory laparotomy, and develop in-hospital compli-
Harborview Medical Center, Seattle,
WA, USA cations. SI ≥1.0 was also a significant predictor of
e-mail: ebulger@uw.edu in-hospital mortality.

© Springer International Publishing AG 2017 133

H.-C. Pape et al. (eds.), Damage Control Management in the Polytrauma Patient,
DOI 10.1007/978-3-319-52429-0_13
134 E.M. Bulger

13.1.2 Prehospital Lactate 94% [15]. The ABC score has been used in some
helicopter EMS services as an indication for pre-
Due to the limitations of traditional vital signs, hospital blood transfusion. As the technology
several authors have assessed point of care lactate evolves and training paradigms are established,
testing as a marker of shock in the prehospital this approach may become more feasible.
setting [6–9]. Lactate is a marker of metabolic
acidosis, which develops with inadequate tissue
perfusion. A number of studies in the hospital 13.2 Damage Control
have demonstrated an association with elevated Management
lactate or a high base deficit and hemorrhagic
shock [10–13]. A recent multicenter trial demon- 13.2.1 Hemorrhage Control
strated that among a trauma population with a Procedures
systolic blood pressure between 70 and
100 mmHG, a prehospital lactate >2.5 mmol/L Traditional management of the severely injured
was a better predictor of the need for resuscitative patients has focused on an ABC approach where
care than SBP or SI [7]. Resuscitative care was airway, breathing, and circulation are assessed
defined as any of the following within 6 h of and managed in that order. While this is still the
emergency department arrival: blood transfusion best approach for the majority of patients, it has
of 5u or greater, operative or angiographic inter- been recognized that in certain circumstances,
vention for hemorrhage control, or death. where there is obvious external bleeding, a CAB
approach may be preferred. This approach has
been endorsed by the US military in the combat
13.1.3 Prehospital ABC Score casualty care guidelines in response to the sig-
nificant number of extremity injuries associated
The ABC score is a scoring system that has been with improvised explosive devices. This approach
used in the emergency department to predict the has also been supported by the Tactical
need for massive transfusion in trauma patients Emergency Care Committee for civilian events
(Table 13.1) [14]. The score assigned points where there still may be an imminent threat and
based on SBP<90 mmHg, HR>120 beats/min, placement of a tourniquet can be accomplished
evidence of penetrating torso trauma, and free much more quickly than airway management.
fluid seen on a focused abdominal sonogram for The American College of Surgeons Committee
trauma (FAST). A score of 2 or greater on ED on Trauma recently published an evidence-based
arrival was associated with a 40% rate of massive guideline for management of external hemor-
transfusion. Efforts to allow this score to be used rhage for civilian EMS providers [16]. For
in the prehospital setting have focused on educa- extremity hemorrhage, this document supports
tion of aeromedical crews to perform ultrasound direct pressure with a hemostatic dressing (if
to assess for intra-abdominal fluid. A recent study available) as the first line of therapy with place-
demonstrated that the sensitivity and specificity ment of a tourniquet whenever direct pressure is
for hemoperitoneum in this setting were 46% and either ineffective or not practical. For junctional
hemorrhage, wound packing with a hemostatic
dressing and direct pressure are advocated. There
Table 13.1  ABC score to predict massive transfusion are a number of junctional tourniquets now on
Variable Points the market, but there is insufficient evidence to
Penetrating mechanism 1 promote their use.
ED SBP of 90 mmHg or less 1 In the civilian community, it is important to
ED HR 120beats/min or greater 1 remember that the majority of life-threatening
Positive FAST exam 1 bleeding in trauma patients is internal bleeding in
FAST focused abdominal sonogram for trauma the chest, abdomen, or pelvis, and thus rapid
13  Prehospital Damage Control 135

t­ riage and transport to a trauma center capable of have been the problem, but rather high rates of
achieving hemorrhage control in the operating hyperventilation and preintubation hypoxia may
room and/or angiography suite is vital. For have impacted outcome [21, 22]. A subsequent
patient with unstable pelvic fracture, there is data review of patients intubated by aeromedical ser-
to support use of a sheet or pelvic binder to help vices who had lower rate of hyperventilation
close the volume of the pelvis and thus poten- demonstrated improved outcome [23]. A ran-
tially reduce venous bleeding. Many patients domized controlled trial of prehospital intubation
with unstable pelvic fractures also have arterial for suspected TBI with low GCS score also dem-
bleeding that will not be controlled with pelvic onstrated improved neurologic outcome in the
binding alone. Thus, these patients need rapid intubated group [24].
transport to the highest-level trauma center Thus, for patients with low GCS or those
available. requiring emergent airway protection, prehospi-
tal intubation is recommended provided that
EMS providers have appropriate training and
13.2.2 Airway Management ongoing skill maintenance [25]. For the sus-
pected TBI patient, patients should be preoxy-
Patients with hemorrhagic shock and intact genated if possible to avoid hypoxia, and
airway who are not at risk for imminent ventilation should be controlled to prevent hypo-
decline should be given supplemental oxygen carbia, which may cause cerebral vasoconstric-
and transported without delay. Patients with tion. End tidal CO2 monitoring has been promoted
airway obstruction, significant airway edema, as a method to monitor appropriate ventilation in
or depressed level of consciousness that sug- the prehospital setting; however, studies have
gest they cannot protect their airway need to shown that end tidal CO2 is not a reliable marker
be supported with bag mask ventilation and of PaCO2 for patients with hemorrhagic shock
ideally placement of a definitive airway based due to decreased pulmonary perfusion [26]. A
on the skill of the EMS provider. Prehospital low end tidal CO2 in this setting is actually more
intubation has been controversial in the litera- predictive of compensated shock than of exces-
ture with wide variation in intubation success sive ventilation. Excessive ventilation which can
rates across the USA [17]. This is in large part increase intrathoracic pressure has also been
due to variability in the training and skill shown to be detrimental in animal models of
maintenance approaches among prehospital severe hemorrhagic shock due to the reduction in
agencies. The ability to use neuromuscular venous return [27, 28].
blocking agents in the field also significantly
improves intubation success rates [18, 19].
There are several rescue devices also available 13.2.3 Needle Thoracentesis
on the market for patients with difficult airway
management. Needle thoracentesis is indicated for patients
Previous studies of prehospital intubation with suspected tension pneumothorax and hemo-
have focused on patients with suspected trau- dynamic compromise. This may occur in the set-
matic brain injury based on a prehospital Glasgow ting of penetrating or blunt chest trauma. Needle
Coma Score (GCS) ≤8. A study by Davis et al. of thoracentesis can be accomplished at the second
rapid sequence intubation in the prehospital set- intercostal space midclaviclular line or fifth inter-
ting suggested worse outcome compared to his- costal space, midaxillary line. Longer needles
torical controls [20]. This study was limited in may be needed for obese patients to ensure
that the cohorts could not be matched based on ­penetration into the chest cavity. There have been
prehospital GCS and so Head AIS score was used few studies of the practical application of needle
instead. Subsequent studies by this research thoracentesis. One study of its use in an urban
group demonstrated that intubation itself may not EMS system did not identify any major safety
136 E.M. Bulger

concerns and reported four patients with hypertonic saline also failed to demonstrate any
­unexpected survival that appeared to be at least in benefit for trauma patients with hypovolemic
part related to rapid chest decompression [29]. shock or severe TBI [33, 34].
In the emergency department, we have
focused on more rapid shift from crystalloid to
13.2.4 Fluid Resuscitation blood product resuscitation. A balanced blood
product resuscitation with early administration
It has been recognized for many years that arti- of ­platelets and plasma in conjunction with red
ficially increasing the blood pressure before blood cells has been associated with improved
hemorrhage control has been achieved can outcome in a number of studies to address the
result in increased bleeding. A landmark study early development of trauma-induced coagulop-
by Bickel et al. randomized patients with pen- athy [35–37].
etrating torso injury in an urban EMS system to These data have led investigators to consider
no fluid administration prior to hemorrhage options for blood and plasma resuscitation to be
control vs. wide open crystalloid resuscitation initiated in the prehospital setting. Several sys-
[30]. In this study, the delayed resuscitation tems have deployed packed red blood cells and
group had a reduction in 24 h mortality. This thawed plasma on aeromedical services, and
led to the concept of hypotensive resuscitation, there is a clinical trial that is currently enrolling
which suggests that for patients with penetrat- patients in an urban ground EMS system with a
ing trauma, a SBP of 80 mmHg or a palpable plasma resuscitation strategy. A recent report by
radial pulse is adequate and crystalloid resusci- Holcomb et al. demonstrated that patients receiv-
tation should be limited until hemorrhage con- ing prehospital blood products had evidence of
trol is achieved. For patients with an SBP, improved acidosis on arrival and a reduction in
<80 mmHg or absence of a radial pulse than subsequent blood product usage, and while there
moderate fluid resuscitation should be adminis- was no difference in 24 h mortality, there was a
tered with a goal of 80 mmHg. Extension of reduction in 6 h mortality among the most criti-
this approach to blunt trauma patients is contro- cally injured patients [38]. There are ongoing
versial as these patients frequently have an efforts in the laboratory to develop freeze-dried
associated TBI and prehospital hypotension has and lyophilized plasma products that will be
been associated with worse outcome for TBI logistically more feasible for use in the prehospi-
patients [31]. tal environment [39, 40].
A recent pilot study of hypotensive resuscita-
tion in blunt trauma patients did not show
impaired outcome, but importantly excluded any 13.2.5 Tranexamic Acid
patient with suspected severe TBI [32]. Thus, for
blunt trauma patients, we advocate a controlled Tranexamic acid (TXA) is an antifibrinolytic
fluid resuscitation strategy which targets a blood drug, which blocks the conversion of plasmino-
pressure that will not put them at risk for impaired gen to plasmin and thus inhibits the breakdown
cerebral perfusion, but avoids excessive resusci- of clot. Fibrinolysis is one component of the early
tation when hypertensive. The other population coagulopathy that can develop in severely injured
of patients for whom traditional blood pressure patients with active hemorrhage. The CRASH-2
goals may not be adequate is the geriatric patient study was a multicenter trial that randomized
with baseline hypertension. injured patients with concern for bleeding to
The next question to address is what fluid is receive TXA vs. placebo within 8 h of injury
ideal for prehosptial resuscitation. Numerous [41]. This study enrolled over 20,000 patients
studies have failed to show any benefit of colloids and demonstrated difference in survival at 14.5%
over crystalloids, and two recent multicenter, for the TXA group vs. 16% for placebo. A sub-
randomized controlled trials of prehospital group analysis suggested better outcome if the
13  Prehospital Damage Control 137

drug was given within 3 h after injury and no 13.2.7 Triage and Rapid Transport
benefit beyond 3 h [42].
This finding has led many to suggest that Current triage recommendations are based on the
perhaps earlier is better and thus the drug CDC Field Triage Guidelines which were last
should be started in the prehospital setting. updated in 2011 [47] (Fig. 13.1). These guidelines
The primary concern with this approach is recommend transport to the highest-level trauma
establishing the appropriate patient selection center available for patients at greatest risk of need-
criteria to avoid exposure of the drug to ing immediate intervention. These include patients
patients who are not likely to benefit. While with hemodynamic instability (SBP <90 mmg),
there were no major safety concerns raised in altered mental status (GCS<14), or respiratory dis-
the CRASH-2 study, several authors have tress (RR <10 or >29 breaths per minute) and
raised concern about potential safety issues patients with signs of significant anatomic injury.
that may not have yet been adequately identi- These patients are at risk for internal hemorrhage
fied [43]. There are several prehospital clini- and thus should be considered as potential damage
cal trials currently enrolling patients that will control patients. Prehospital procedures should be
address these issues. For agencies that have limited to the lifesaving interventions as discussed
decided to implement TXA protocols, a guid- above with a focus on minimizing scene time.
ance document emphasizing the importance of Recent data has demonstrated that the CDC field
coordination with the regional trauma system triage criteria do not perform as well when assess-
has been published by the American College ing elderly trauma patients. Thus, elderly patients
of Surgeons Committee on Trauma in con- require a high index of suspicion for occult hypo-
junction with the National Association of perfusion, even with what appears to be a normal
EMS Physicians and the American College of blood pressure, and significant injury despite a
Emergency Physicians [44]. minor mechanism event.
In order to minimize scene times, recent
emphasis has been placed on improved coordina-
13.2.6 Avoiding Hypothermia tion between EMS and law enforcement to opti-
mize EMS access to the scene for major shooting
Hypothermia in injured patients has been asso- events with rapid patient evacuation. A series of
ciated with increased mortality [45]. This is due conferences known as the Hartford consensus
in part to the effects of hypothermia on the conferences have laid out strategies to enhance
exacerbation of coagulopathy. Studies have hemorrhage control education for law enforce-
shown that the majority of trauma patients that ment, encourage joint training between EMS and
arrive in the ED are hypothermic despite nor- law enforcement, and body armor protection for
mal ambient temperatures [46]. Patients are EMS providers to facilitate access to a warm
often exposed to the elements, clothing has zone more rapidly [48–51].
been removed to provide medical care, and There is controversy regarding the optimal use
shock which leads to peripheral vasoconstric- of aeromedical transport to facilitate triage to a
tion can lead to additional heat loss. It is impor- higher-level trauma facility, while not extending
tant to recognize this risk and take steps to scene time [52]. In an urban setting when trans-
avoid additional heat loss by removal of wet port time to major centers is short, then delaying
clothing, covering the patient with blankets, ground transport to await helicopter arrival is
and administering warm IV fluids whenever likely not beneficial. However, there are a num-
possible. Blood products in particular are gen- ber of studies that have demonstrated worse out-
erally stored at 4C and thus need to be warmed come for patients injured in a rural setting, and
when administered. For prehospital administra- delays in access to high-level trauma center may
tion, there are in-line warmers that can be play a role. Two recent studies support the use of
attached to the IV tubing. aeromedical transport to facilitate access to major
138 E.M. Bulger

Measure vital signs and level of consciousness

Step One Glasgow Coma Scale ≤13

Systolic Blood Pressure (mmHg) <90 mmHg
Respiratory rate <10 or >29 breaths per minute*
(<20 in infant aged <1year),
or need for ventilatory support

Transport to a trauma
No center. Steps One and Two
atempt to identify the
most seriously injured
Assess anatomy Yes patients. These patients
of injury should be transported
preferentially to the
highest level of care within
Step Two§ - All penetrating injuries to head, neck, torso and extremities proximal to elbow or knee
the defined trauma system
- Chest wall instability or deformity (e.g., flail chest)
- Two or more proximal long-bone fracture
- Crushed, degloved, mangled, or pulseless extremity
- Amputation proximal to wrist or ankle
- Pelvic fractures
- Open or depressed skull fracture
- Paralysis

No

Assess mechanism of
injury and evidence of
high-energy impact

Step Three§ • Falls

— Adults; > 20 feet (one story is equal to 10 feet)
— Children1; > 10 feet or two or three times the height of the child Transport to a trauma
• High-risk auto crash center. Which, depending
— Intrusion, ** including roof: >12 Inches occupant site; > 18 inches any site upon the defined trauma
Yes
— Ejection (partial or complete) from automobile system, need not be the
— Death in same passenger compartment highest level trauma
— Vehicle telemetry data consistent with a high risk of injury centera.††
• Auto vs. pedestrian/bicyclist thrown, run over, or with significant (>20 mph) impact
• Motorcycle crash >20 mph

No

Assess special patient or

system considerations

Step Four • Older adults11

— Risk of injury/death increases after age 55 years
— SBP <110 might represent shock after age 65 years Transport to a trauma
— Low impact mechanisms (e.g. ground level falls) might result in severe injury center or hospital capable
• Children of timely and thorough
— Should be triaged preferentially to pediatric capable trauma centers evaluation and initial
• Anticoagulants and bleeding disorders Yes
management of potentially
— Patients with head injury are at high risk for rapid deterioration serious injuries. Consider
• Burns consultation with medical
— Without other trauma mechanism; triage to burn facility*** control.
With trauma mechanism; triage to trauma center***
• Pregnancy > 20 weeks
• EMS provider judgment

No

Transport according
to protocol†††

When in doubt transport to a trauma center

Fig. 13.1  CDC field trauma triage algorithm: 2011 (From CDC web site: www.cdc.gov/mmwr/preview/mmwrhtml/
rr6101a1.htm)
13  Prehospital Damage Control 139

trauma centers. Brown et al. utilized the National 5. Pandit V, Rhee P, Hashmi A, et al. Shock index pre-
dicts mortality in geriatric trauma patients: an analysis
Trauma Databank to compare patients trans-
of the National Trauma Data Bank. J Trauma Acute
ported by helicopter vs. ground transport. While Care Surg. 2014;76(4):1111–5. doi:10.1097/
patients transported by helicopter were more TA.0000000000000160.
severely injured, had longer transport times, and 6. Shah A, Guyette F, Suffoletto B, et al. Diagnostic
accuracy of a single point-of-care prehospital serum
required more hospital resources, they were more
lactate for predicting outcomes in pediatric trauma
likely to survive and be discharged home after patients. Pediatr Emerg Care. 2013;29(6):715–9.
their injury [53]. Another study focused on doi:10.1097/PEC.0b013e318294ddb1.
patients with evidence of shock or traumatic 7. Guyette FX, Meier EN, Newgard C, et al. A comparison
of prehospital lactate and systolic blood pressure for pre-
brain injury in the prehospital setting and again
dicting the need for resuscitative care in trauma trans-
demonstrated higher injury severity, longer trans- ported by ground. J Trauma Acute Care Surg.
port times, and more prehospital procedures 2015;78(3):600–6. doi:10.1097/TA.0000000000000549.
among those transported by air but no difference 8. Guyette F, Suffoletto B, Castillo J-L, Quintero J,
Callaway C, Puyana JC. Prehospital serum lactate as a
in survival based on mode of transport [54].
predictor of outcomes in trauma patients: a retrospec-
tive observational study. J Trauma. 2011;70(4):782–6.
doi:10.1097/TA.0b013e318210f5c9.
13.3 Summary 9. Mullen M, Cerri G, Murray R, et al. Use of point-of-­
care lactate in the prehospital aeromedical environ-
ment. Prehosp Disaster Med. 2014;29(2):200–3.
The principles of damage control management doi:10.1017/S1049023X13009254.
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pital setting and thus influence decision-making Kerby JD. Lactate is a better predictor than systolic
blood pressure for determining blood requirement and
regarding lifesaving interventions, fluid and
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blood product resuscitation, and rapid triage and triage? J Am Coll Surg. 2010;210(5):861–7, 867–9.
transport to the most appropriate trauma center. 10.1016/j.jamcollsurg.2010.01.012.
Early identification of the patient in hemorrhagic 11. Kaplan LJ, Kellum JA. Initial pH, base deficit, lactate,
anion gap, strong ion difference, and strong ion gap
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 Phase I: Abbreviated Surgery
(General Surgery)
14
Brian P. Smith and Patrick M. Reilly

A routine approach to accessing cavities, packing patients with many specific injury complexes
the operative field, and establishing adequate such as pelvic fractures or solid organ injuries,
retraction and exposure is paramount to setting TBI remains a significant risk factor for death
the tone of the operation and optimizing chances [4, 5]. Because of the relative frequency with
of success. Furthermore, the team must remain which they occur in combination with other
mindful that multiple injuries will evolve in par- injuries, the trauma surgeon must be able to
allel and frequent re-triage, and prioritization of recognize and at times temporize head injuries
intervention is necessary for patient survival. On that threaten each patient’s life.
occasion, multiple teams of surgeons will need to
operate in different cavities simultaneously. The
importance of efficient and cooperative team- 14.1.1 Traumatic Brain Injury
work cannot be understated.
Detailed management of TBI can be found else-
where within this text. However, the trauma sur-
14.1 Head geon must be able to recognize basic signs of
injuries that are associated with TBI. Loss of
Injuries in the head can manifest in several dif- consciousness, depressed mental status, and neu-
ferent ways. They range from innocuous inju- rologic deficits (particularly lateralizing signs)
ries with no outward signs of trauma to are common indicators of TBI. If time and physi-
devastating traumatic brain injury (TBI). ology permit, computed tomography of the brain
Among all injured patients, TBI remains the is an excellent test for the detection of TBI. For
leading cause of death [1–3]. And among patients with severe injuries that necessitate
immediate operation, the surgeon is faced with
B.P. Smith, MD (*) challenging decisions. Options range from fore-
Assistant Professor of Surgery at HUP & PPMC, going central nervous system imaging until
Perelman School of Medicine, definitive management of other life-threatening
University of Pennsylvania, Philadelphia,
Pennsylvania, USA injuries is obtained to prioritizing medical imag-
e-mail: brian.smith2@uphs.upenn.edu ing even in the face of hemodynamic instability
P.M. Reilly, MD [6, 7]. The latter approach has gained some favor
Professor of Surgery at HUP, as CT scanning technology evolves, and images
Division of Trauma and Surgical Critical Care, can be obtained faster and with better proximity
Department of Surgery,
to trauma bays and operating theaters.
Perelman School of Medicine, Philadelphia,
Pennsylvania, USA Alternatively, the brain can be triaged dur-
e-mail: reillyp@uphs.upenn.edu ing emergency surgery of another cavity with

© Springer International Publishing AG 2017 143

H.-C. Pape et al. (eds.), Damage Control Management in the Polytrauma Patient,
DOI 10.1007/978-3-319-52429-0_14
144 B.P. Smith et al.

p­ ortable CT technology if available or insertion of nasal tampons. Posterior packing can also be
an intracranial pressure monitor. Empiric decom- achieved with inflatable nasal balloon catheters.
pressive craniectomy during or temporally related In the absence of that device, a large Foley uri-
to other surgeries has also been described when nary catheter can be inserted into a nostril, the
lateralizing symptoms are observed. We recom- balloon expanded, and gentle traction applied to
mend involvement of a neurosurgical specialist if hold the balloon in place. Balloons can also be
available to help with this decision-making. directly inserted into injury tracts to obliterate
hemorrhagic spaces. Mortality rates of patients
that undergo emergency control of facial hemor-
14.1.2 Scalp and Soft Tissue Injuries rhage are high (approaching 90%) due largely to
massive hemorrhage and concomitant injuries
Lacerations of the face and skull can prove prob- [8]. Catheter angiography and embolization are
lematic for the trauma surgeon who is trying to useful adjuncts for definitive control of facial and
care for other injuries because of the large vol- pharyngeal bleeding [9, 10].
ume of blood loss that can occur from these sites.
This is particularly true for patients who are anti-
coagulated. The first line of therapy should be 14.2 Neck
gently direct pressure over the source of bleeding
with a gloved hand. Basic absorptive dressings The confines of the neck, combined with the
should be used and can be supplemented with large number of organ systems that exist in and
hemostatic dressings (such as any kaolin- or pass through it, make it a challenging field in
chitosan-­based product). If basic maneuvers fail which to operate. A slight shoulder role will help
to stop bleeding, temporizing sutures (so-called to gently extend the neck, and the head should
whip stitches) can be utilized. Raney clips also not be placed too much to either side as injuries
provide rapid and effective hemorrhage control generally traverse from one side to the other.
for some lacerations. In such cases, we prefer an
automated reloading clip applier rather than the
traditional manual loading Raney clip forceps. 14.2.1 Vascular
Regardless of the hemorrhage control technique,
the surgeon must remember to revisit the wound Injuries to the carotid and vertebral vessels
and perform any necessary debridement and irri- account for 26.7% of all injured blood vessels in
gation prior to definitive closure once other patients with vascular injuries [11]. The optimal
sources of hemorrhage have been addressed. incision for hemorrhage control in the neck is
unknown as injuries can cross multiple zone and
sides. However, the standard longitudinal inci-
14.1.3 Nasopharyngeal sion along the anterior border of the
and Oropharyngeal Bleeding sternocleidomastoid does provide access to a
­
majority of the length of most vessels.
The primary maneuver for dealing with bleeding Additionally, it can be extended onto the sternum
from the mouth or nose is the protection of the should sternotomy be necessary.
airway. Once the lungs are protected with an We favor mandatory exploration of all carotid
endotracheal tube or surgical airway, the source sheath hematomas in the absence of preoperative
of bleeding can be addressed. Numerous tech- imaging. Bleeding that arises from the carotid
niques have been described for emergency con- arteries is controlled with proximal and distal
trol of pharyngeal bleeding. Most of these involve occlusion as with any other vascular surgery.
tamponade of bleeding spaces. The nares can be Patients presenting with isolated carotid injuries
packed with gauze or commercially available and stable hemodynamics should undergo pri-
14  Phase I: Abbreviated Surgery (General Surgery) 145

mary repair of the injury [12]. If there are other the patient leaves the resuscitation area. In that
compelling sources of hemorrhage, the carotid regards, tracheal trauma will rarely impact the
should be shunted with an appropriately sized surgeon’s decision to abbreviate the operation in
conduit until such time that repair is possible. For a damage control fashion. Tracheal injuries
isolated carotid arterial injuries, temporary shunt- encountered during neck exploration should be
ing does not appear to offer an advantage [13]. repaired if the patient’s physiology permits.
We recommend irrigation with heparinized Primary anastomosis with 4-0 oiled vicryl or
saline, passage of Fogarty balloon catheters dis- absorbable monofilament suture is preferred
tally, as well as forward and back bleeding prior [16]. Repairs should be protected with vascular-
to insertion of shunts and definitive repairs. In ized tissue such as strap muscle. There is little
rare cases the carotid vessels can be ligated in data to support or refute the drainage of tracheal
order to expedite surgery in a patient who is repairs in the neck. In the context of an abbrevi-
dying from other injuries. The risk of persistent ated surgery for trauma, temporary drainage
neurologic defect after ligation is hard to esti- should be strongly considered.
mate because of frequently associated injuries;
however, many small series report a stroke rate
around 50% [13, 14]. 14.2.3 Esophagus
Bleeding that persists despite control and
exposure of the carotid system most likely arises Injuries to the esophagus are rare, and slightly
from the vertebral artery. These exposures can be less than half of all esophageal injuries occur
particularly challenging because of the deep in the area of the cervical esophagus [17].
location of the vertebrals in the neck and their Several algorithms have been described
confinements in the osseous canal. This makes regarding the evaluation and management of
proximal and distal control particularly challeng- suspected cervical esophageal injuries [17–
ing. These wounds should be packed with bone 21]. Clinical indicators of injury, or imaging
wax in the area of injury. Definitive proximal that demonstrates trajectory involving or adja-
control can be obtained by dividing the manu- cent to the esophagus, generally mandate sur-
brial origins of the sternocleidomastoid and ster- gical exploration.
nohyoid muscles and isolating the vertebrals Patients brought directly to the operating
after they arise from the subclavian arteries. room because of instability or associated injuries
Catheter angiography and embolization of these should be formally explored through an anterior
injuries are also a useful approach [15]. sternocleidomastoid, collar incision, or bilateral
Damage control surgery in the neck leaves sternocleidomastoid incision if necessary. The
little room for repair of venous injuries. These area of the esophagus in question should be fully
wounds should be ligated to facilitate repair of mobilized and explored. Care must be taken to
other life-threatening problems. avoid injury to the recurrent laryngeal nerves. If
the surgeon is unable to identify perforation in
areas suspicious for injury, adjuncts such as
14.2.2 Trachea esophagoscopy or instillation of methylene blue
might be helpful. If patient physiology precludes
As with oral and pharyngeal injuries, tracheal prolonged exploration, the area should be well
injuries mandate protection of the airway with an drained, and additional testing (such endoscopy
endotracheal tube of a surgically created crico- or contrast imaging) should be conducted as soon
thyroidotomy or tracheostomy. Occasionally, the as other life-threatening problems have been
traumatic injury itself will create an opening resolved.
through which the airway can be accessed. Nondestructive injuries should be debrided to
Generally the airway should be secured before healthy tissue and closed. There are no
146 B.P. Smith et al.

r­andomized controlled trials comparing one- to

two-­layered closure in trauma. We do recom-
mend that closed tissue should be healthy and
tension-free [22]. Injuries that result in obvious
perforation should be closed in the same fashion.
Special consideration should be given to perfora-
tions in order to exclude a second adjacent injury
resulting from a “through-and-through” trajec-
tory. The closure of esophageal injuries over a
nasoenteric tube for gastric drainage/feeding and
protection of the repair with vascularized tissue,
such as an infrahyoid muscle, are generally rec-
ommended [17].
Destructive injuries such as complete tran-
section can be more challenging to manage.
This is particularly true if the distal esophagus
has retracted into the mediastinum or is ­difficult Fig. 14.1  The surgeon must know the advantages and
to find because of concomitant soft tissue limitations of various thoracic surgical exposures
injury. If the surgeon is unable to identify the
distal esophagus, we recommend laparotomy, 14.3.1 Emergency Thoracotomy
gastrostomy, and retrograde cannulation of
the esophagus. This aids identification of the Emergency department (ED) thoracotomy has
distal cervical esophagus, which can be closed indications for injuries beyond isolated thoracic
as a stump. The stomach opening can then be wounds. However, it is most commonly per-
converted to a gastrostomy tube for drain-
­ formed on patients with thoracic injuries.
age and/or feeding. The proximal esophagus Absolute indications and contraindications to the
should be matured as an end cervical procedure are not well agreed upon [23–26].
esophagostomy. Adjuncts to the history and physical exam, such
as cardiac ultrasound, have been suggested as
tools to aid clinical decision-making [27]. Once
14.3 Thorax the decision is made, the surgeon should proceed
with speed and proficiency. We recommend abso-
Thoracic surgery for the trauma patient gener- lution of the surgeon from team leader responsi-
ally takes the form of thoracotomy or sternot- bilities regarding the medical part of the
omy, and deciding which incision to make is resuscitation (if possible) when the surgeon par-
sometimes challenging (Fig. 14.1). The trauma ticipates in the thoracotomy. ED thoracotomy
surgeon should have a good understanding of should not delay other lifesaving maneuvers such
which exposures each incision has to offer, as as decompression of the right chest with thora-
well as slight modifications that can be used to cotomy, control airway for ventilation, and intra-
facilitate certain procedures. For instance, the venous or intraosseous access for volume
so-called taxi hailing position (supine with resuscitation.
single hemithorax 30° elevation and ipsilateral The procedure starts with a rapid prep of the
arm overhead adduction) allows adequate chest wall. The left arm should be raised above
exposure for thoracotomy while preserving the head. The skin is incised at the inframammary
the abdomen for laparotomy and the contralat- cleft in the area of the fourth or fifth interspace.
eral hemithorax for bilateral thoracotomy if The incision should extend from the sternum
needed. through serratus anterior to latissimus dorsi. The
14  Phase I: Abbreviated Surgery (General Surgery) 147

incision should then be deepened to the intercos- a­nteriorly and posteriorly in a perpendicular
tals. Next, the intercostals should be divided. We fashion at the level of an intervertebral disk. This
prefer a large set of curved Mayo scissors to ride avoids avulsion of the spinal arteries originating
the top edge of the rib anteriorly and posteriorly. from the mid vertebral level. The vascular clamp
A self-retaining rib spreader (such as a Finochietto is then applied with care, taken to avoid injuring
retractor) should be placed with the spreading bar the esophagus. Timing of aortic cross-clamping
(or “U bar”) toward the stretcher. This technique should be noted, and efforts to remove or replace
preserves access to the sternum in the case that the clamp in a more favorable position should be
the procedure be converted to a bilateral anterior expedited.
thoracotomy. Life-threatened hemorrhage from the lung can
At this time, it is often helpful to direct the be temporized with manual direct pressure. This
airway team to hold ventilation. This affords the can be supplanted with a Duval lung clamp. We
surgeon better access to the pericardium and have not had success with more advanced lung
descending thoracic aorta. The pericardium procedures in the resuscitation bay and believe
should be incised anterior to the left phrenic that suture ligation of lung bleeding or tractot-
nerve from the apex to the proximal aorta. omy should be performed in the operating room
Hemopericardium should be evacuated and the with better lighting, exposure, and instrumenta-
heart delivered. A quick inspection of the heart tion. Bleeding that does not stop with direct pres-
will reveal any injuries. Once the source of bleed- sure should be temporized with pulmonary hilar
ing has been identified, bag ventilation should be control. This is generally easier to perform from
resumed. We advise primary control of cardiac or the opposite side, with one hand passing cepha-
proximal major vascular injuries (aortic root, lad and one passing caudal to the lung hilum. The
cava, pulmonary artery, etc.), prior to clamping nondominant hand can manually occlude the
the descending thoracic aorta as the increased hilum and guide the insertion of a clamp.
afterload will compound bleeding from these Alternatively, the technique preferred by this
vessels. Oftentimes, major hemorrhage can be group is manual occlusion and placement of a
controlled with a gloved finger as supplies and Rumel tourniquet using umbilical tape. A large
instruments are gathered for more definitive con- angled or curved Debakey clamp can be used to
trol. A surgical skin stapler is a rapid and effec- pass the tape posterior while manual occlusion is
tive way to decrease hemorrhage from cardiac maintained. Once in place, this technique allows
injuries. This technique is usually supplemented the surgeon to operate with both hands, affords a
with pledgeted suture repair. We favor leaving lower profile than a large clamp for better visual-
the original staples in place once the repair is ization, and might generate less hilum trauma
complete. Small vascular clamps are also effec- than a mechanical clamp.
tive in controlling atrial injuries prior to defini- Finally, it is important to mention that in the
tive closure. Special consideration should be absence of definitive knowledge of a normal
given to injuries in proximity to coronary arter- right pleural space, the right chest should be tri-
ies. These wounds should be closed with pled- aged in some fashion. Finger or tube thoracotomy
geted horizontal mattress sutures outside of the is a commonly used technique. Alternatively, the
adjacent coronary artery [28]. surgeon can also open the right pleural space
Patients remaining in extremis after central through the left chest by dissecting under the
bleeding has been temporized should undergo sternum across the anterior precordial mediasti-
cross-clamping of the thoracic aorta. This is done num. If no assistant is present, the surgeon should
by retracting the left lung cephalad. The aorta can give strong consideration to bilateral anterior
be palpated and manually occluded against the thoracotomy. Some surgeons prefer this incision
vertebral bodies, and a straight vascular clamp is for ED thoracotomy regardless of mechanism or
obtained. Next the parietal pleura is opened assistant availability [29]. Regardless of incision,
148 B.P. Smith et al.

the surgeon should be quick to move the patient As mentioned previously, definitive repair of
to a more controlled operating space once hemor- cardiac wounds should be performed with a 3-0
rhage is temporized. or 4-0 permanent monofilament suture. Large
needles are commonly employed to span the
defects, and pledgets or large felt buttresses can
14.3.2 Heart be used to minimize cardiac muscle damage.
After hemorrhage is controlled, and injuries to
Traumatic injuries in the heart are rarely man- other structures have been ruled out, the patient
aged with abbreviated surgery. Temporizing can be discharged to the ICU for resuscitation
maneuvers might be employed to control hemor- and monitoring. The pleural spaces and pericar-
rhage until the patient can be moved to a more dial spaces should be drained. There are no ran-
favorable operating environment (as mentioned domized controlled studies evaluating the role of
previously), better instrumentation is obtained, or pericardial closure after cardiac surgery for
expanded surgical expertise is consulted. trauma. Data from the elective cardiac surgery
Generally speaking, however, most traumatic literature is mixed [35].
cardiac injuries are definitively repaired at the
index operation. Most cardiac injuries are more
easily approached through a median sternotomy. 14.3.3 Great Vessels (Cava,
If patient physiology permits and the suspicion Pulmonary Arteries,
for posterior mediastinal injuries is low, median Pulmonary Veins, and Aorta)
sternotomy is the incision of choice [29]. If there
is concern for pericardial tamponade, we recom- Data regarding the management of traumatic
mend prepping and draping the patient awake injuries to these vessels is sparse, and they are
and gowning and surgical preparation prior to the usually grouped into a common category. Many
induction of anesthesia. This allows the surgical injuries to these vessels are more easily and suc-
team to rapidly enter the chest if tamponade cessfully managed by way of endovascular
physiology develops. The patient in extremis approaches. However, the selection bias of those
should be approached through a left anterolateral reports is critical as many of those patients fall
(or bilateral) thoracotomy. outside the purview of traditional damage control
Surgical cardiac injuries most commonly surgery. Those patients who do require open sur-
result from penetrating mechanisms [30]. gical intervention are best served with direct
Frequently, these patients have active bleeding suture repair of the injured vessel.
or signs of shock or death that necessitate surgi- Injuries to the superior vena cava can be con-
cal intervention. Many variables have been trolled with vessel loops above and below the
associated with patient outcomes, particularly level of injury. Side-biting vascular clamps or
the mechanism of injury, the presence of signs end-biting (such as Allis) clamps placed adjacent
of life during evaluation, and the number of to one another along the length of the injury can
injuries to the heart and great vessels [31–34]. It eliminate or slow bleeding enough to repair the
is common for penetrating injuries (particularly vessel. Care should be taken to minimize narrow-
gunshot wounds) to cause multiple holes; there- ing of the vessel. More destructive injuries might
fore diligent inspection (including the intraven- require vein patch to preserve patency. Data on
tricular septum) is required. Early utilization the utility of antiplatelet therapies and anticoagu-
extra corporeal membrane oxygenation and lation after repair of caval injuries is lacking.
transesophageal echocardiography might aid in Venous air embolism is a potential complication
diagnosis and repair of near lethal injuries. of large caval injuries. The treatment for this
Currently, the mortality of patients with multi- problem involves steep Trendelenberg position-
ple cardiac and great vessel injuries remains ing to trap the gas in the right ventricular apex,
extremely high [34]. preserving blood flow through the ventricular
14  Phase I: Abbreviated Surgery (General Surgery) 149

outflow tract. The ventricle can also be aspirated and diagnosed using cross sectional imaging),
through the cardiac wall, or by way of an endo- should be repaired by way of endovascular stent-
vascular approach. Reports of this technique are ing [40–43]. There is little role for open repair as
limited to case studies. the morbidity and mortality of this approach
Pulmonary artery (PA) injuries should be pri- remains high. There is probably a role for tech-
marily repaired. Like many cardiac wounds, nology, such as Rapid Endovascular Balloon
pledgets can be used to minimize further tissue Occlusion of the Aorta (REBOA), even in open
damage and distribute the suture tension across cases using a hybrid open/endovascular approach.
the wound. Posterior and distal PA injuries might To date, however, this role is poorly understood.
necessitate the use of cardiopulmonary bypass to
adequately expose and control the injury.
Pulmonary venous injuries that survive to 14.3.4 Trachea and Bronchi
operation are uncommon. Descriptions in the lit-
erature consist mostly of case reports. They pres- Most injuries of the distal large airways result
ent in two varieties: intrapericardial rupture that from blunt mechanisms and are suspected
occasionally involves the left atrium and presents because of large, ongoing air leak after pleural
as hemopericardium or intrapleural rupture pre- evacuation of pneumothorax [44]. Diagnosis
senting as massive hemothorax. Some authors should be confirmed with bronchoscopy, and
have described repair of intrapericardial wounds these injuries should be primarily repaired and
without the assistance of cardiopulmonary bypass buttressed with healthy tissue in a semi-urgent
[36–38]. However, the elevation of the heart to fashion. In this regard, there is little that needs to
expose these vessels typically results in decreased be done at index operation if a tracheal or bron-
preload followed by hemodynamic instability. chial injury is encountered and the surgeon is
Therefore, the surgeon should be prepared to ini- eager to abbreviate the operation for other rea-
tiate bypass if it is necessary for adequate expo- sons. Simple injures can be primarily closed. In
sure and repair [39]. Extrapericardial wounds the absence of respiratory failure resulting from
care can generally be controlled manually or with air leak, more complex injuries should be man-
the assistance of a balloon catheter. If ligation of aged with wide pleural drainage and evacuation
the pulmonary vein is required, the correspond- of pneumothorax until such time that definitive
ing lobe of the lung should be considered for repair is possible.
resection. However, the optimal timing of this
procedure is not known.
Injuries to the thoracic aorta that are encoun- 14.3.5 Lungs
tered during open surgery are primarily repaired
with sutures. As with some other complex great As mentioned previously, massive pulmonary
vessel injuries, wounds that involve posterior hemorrhage can be controlled with direct pres-
surfaces or the transverse arch, where the origins sure or segmental/hilar vascular control.
of the right brachiocephalic and the left carotid Peripheral injuries can be wedge resected using
and/or subclavian arteries originate, might bene- surgical stapling devices. The use of tractotomy
fit from cardiopulmonary bypass to reconstruct. procedures is well described and accepted to con-
The wounds can be balloon occluded temporarily trol hemorrhage emanating from within and lung
if necessary. To our knowledge, shunting of the parenchymal injury. Staples with 2.5–3.5 mm leg
arch vessels as a maneuver to abbreviate the lengths generally work for this procedure.
index operation has not been described. Bleeding vessels in the now open tract should be
Stable patients, in whom an aortic injury is controlled with 3-0 or 4-0 mattressed sutures.
diagnosed before bringing the patient to the oper- Topical hemostatic agents can be used to supple-
ating room (this sample of patients is, over- ment the sutures in the event of minor bleeding.
whelmingly, people injured by blunt mechanisms Low volume air leaks can also be managed with
150 B.P. Smith et al.

pleural drainage and pressure-controlled ventila- of gunshot thoracic esophageal injuries with cov-
tion in order to abbreviate surgery if necessary. ered stents is undescribed otherwise.
Emergency lung resection, although rare Authors have also described T-tube drainage
(incidence of 0.08–1.3%), is associated with high of penetrating esophageal injuries in patients
morbidity and mortality, especially when a pneu- who cannot undergo official repair due to other
monectomy is required [45, 46]. The majority of reasons [17, 52]. This provides a rapid means of
studies have been limited to small single-center drainage and preserves tissue for delayed recon-
reports with great variability. The contribution of struction after resuscitation is complete.
fulminant right heart failure to mortality in the
setting of emergency pneumonectomy is an often
mentioned but poorly understood phenomenon. 14.3.7 Temporary Thoracic Closure
As prolonged hilar occlusion and deferred major
pulmonary resections have been described as Patients requiring damage control surgeries can
treatment strategies for refractory pulmonary undergo temporary chest closure in order to
bleeding, the surgeon should give strong consid- abbreviate operating time. Several techniques
eration to damage control strategies in these have been described, and there is no scientific
cases [47]. Inhaled prostacyclin should be con- evidence to support one approach over another.
sidered for patients with evidence of right ven- We prefer to drain all entered spaces. Pleural
tricular failure awaiting definitive management spaces can be controlled with standard chest
of major pulmonary resection [48, 49]. tubes. Generally, we use one tube on each side,
brought out through the skin in a standard posi-
tion. We prefer large Blake drains for the pericar-
14.3.6 Esophagus dium and mediastinum. These can be brought out
through the incisions to preserve skin and drain
Blunt traumatic thoracic esophageal injuries are locations for the planned washout and closure.
very rare, and most wounds to this region of the We create a visceral covering by sandwiching
esophagus are caused by gunshot injuries [50, a 6 in. Esmarch tourniquet between two pieces of
51]. Wounds should be closed primarily with Ioban with the adhesive side facing inwards. The
careful attention to approximation of the mucosal Esmarch is cut slightly longer than the incision,
layer. Like all esophageal perforations, we rec- and the Ioban should overlap the Esmarch on
ommend wide drainage of the affected mediasti- every side. In the absence of Esmarch tapes, sur-
nal and pleural spaces. Flap protection of the gical towels or any other device to add integrity
closure can be delayed if damage control surgery to the Ioban can be substituted. This bandage is
is being conducted, during such time, the lumen then placed in the wound, under the chest wall to
of esophagus/stomach should be aggressively cover the visceral pleura. The incision is then
drained. gently reduced manually. Surgical towels or
Exposure of the injured segment can be chal- sponges are then laid into the wound, and a large
lenging, particularly in the area below the tra- adhesive dressing is applied to the entire incision.
cheal bifurcation and behind the heart. We have Care should be taken to seal any drains that are
successfully treated a gunshot wound in this brought out through the dressing.
region complicated by a through-and-through-­ The surgeon should also note the airway pres-
type injury of the proximal pulmonary artery sures that are present before and after the dress-
using a covered esophageal stent. Esophagoscopy ing is applied to reduce the risk of generating
was used intraoperatively to diagnose the injury thoracic compartment syndrome. Nonsurgical
(based on trajectory), and the stent was deployed bleeding resulting from trauma-induced coagu-
in the ICU as the patient required ongoing extra- lopathy can be controlled with packing. In these
corporeal membranous oxygenation as a sequel cases, monitoring airway pressures, as well as
of the PA injury. To our knowledge, the treatment gas exchange, is critical.
14  Phase I: Abbreviated Surgery (General Surgery) 151

14.4 Abdomen 14.4.2 Liver

Of the various body regions in which a trauma Restoration of normal liver anatomy is a simple
surgeon might operate, the abdomen is generally maneuver that helps slow bleeding from the
regarded as the most familiar. And while injury injured surface. The shape can then be main-
patterns are often seen from one patient to the tained and buttressed by the addition of dry surgi-
next, it is important to remember that no two cal laparotomy pads, and it can generally be
patients are identical. Systematic exploration and performed without any formal mobilization of
frequent reassessment of operative progress, the suspensory ligaments. If the bleeding contin-
patient physiology, and evolving plans ensure ues, the surgeon should arrest vascular inflow by
adequate and timely surgery. application of a Pringle maneuver [62, 63]. This
is performed by manual occlusion of the porta
hepatis and division of the pars flaccida. We pre-
14.4.1 Laparotomy fer vessel loop occlusion of the porta as the low
profile of the loop (as opposed to a vascular
A midline laparotomy extending from the xiphoid clamp) facilitates easier operating in the right
process to the pubis symphysis is a typical inci- upper quadrant. If the bleeding stops with the
sion for torso hemorrhage control. The process application of a Pringle, the course is most likely
should be performed quickly, and the exploration portal venous or hepatic arterial in nature. The
should occur in a systematic fashion to inspect injury should be gently extended and explored.
for bleeding. The surgeon should consider a bilat- Bleeding vessels can be ligated, clipped, or occa-
eral subcostal incision for patients who have sionally controlled with linear stapling devices.
undergone previous laparotomy. This should be Care should be taken to avoid exacerbation of the
lower than a standard chevron, allowing better injury. Hepatic arterial bleeding is generally ame-
access to the pelvis. nable to catheter embolization (Fig. 14.2).
Once the abdomen is open, hemoperitoneum Ongoing liver bleeding that persists despite
is temporized with packing. This should allow application of a Pringle maneuver suggests
sufficient time to establish a self-­ retaining hepatic venous injury. These injuries and those
retractor. The surgeons should then examine all limited to the retrohepatic vena cava carry high
zones of the retroperitoneum, solid organs, deep mortality rates. If the bleeding arises from a
pelvis, and hollow viscera for a sign of bleed- branch or segmental branch of the hepatic vein,
ing. Autologous transfusion of shed blood is a the injury should be suture ligated. Exposure of
useful strategy. Although not ideal, shed blood
can be used in the face of hollow visceral injury
[53, 54].
There has been recent interest in the use of
endovascular balloon catheters to help control
hemorrhage as surgical procedures are initiated.
Studies have attempted to compare outcomes
relative to resuscitative ED thoracotomy and
quantify blood loss during the time leading up to
definitive surgery [55–61]. The use of endovas-
cular aortic balloon occlusion in a highly lethal
swine model was associated with higher blood
pressures and lower mortality compared to ani-
mals bled without the device [57]. Demonstration
of such outcomes in humans, however, remains Fig. 14.2 Catheter angiogram demonstrating hepatic
limited. arterial bleeding
152 B.P. Smith et al.

the hepatic veins is performed directly through ing solution. However, it might be time-­
large wounds, or by mobilizing the right or left consuming if several injuries need to be
lobes of the liver based on the branch suspected addressed. Surgical clamps such as Allis and
to contain the injury. Babcock clamps provide speed but can be cum-
Other advanced surgical techniques for refrac- bersome as the bowel is examined and manipu-
tory liver bleeding include the use of an atrioca- lated. We often used umbilical tape passed
val shunt or venovenous bypass after total through small defects at the mesenteric border
vascular occlusion of the liver with a Pringle and gently ties around the hollow visceral inju-
maneuver and suprahepatic (or intrapericardial) ries. This provides a type a “proximal and distal”
and suprarenal inferior vena cava occlusion. hollow visceral control and allows the surgeon to
Mounting evidence suggests, however, that inju- reassess which injuries can be repaired primarily
ries to the retrohepatic vena cava or deep intrapa- and which should be formally resected during a
renchymal liver might be served better with more favorable part of the operation. It is impor-
extensive perihepatic packing to restore anatomy tant to note the gastrointestinal continuity can be
and complimentary angioembolization to rule out deferred to a later operation during cases when
arterial injury [63–66]. the surgeon is trying to abbreviate emergency
laparotomy. However, consideration should be
given to proximal injuries (duodenal and jejunal),
14.4.3 Spleen particularly if there are upstream wounds.
Managing these injuries with “blind ends” for
The spleen is a commonly injured organ, and it prolonged periods of time might compromise
can be the source of life-threatening hemorrhage. upstream repairs.
And while nonoperative management of spleen
injuries has become commonplace, there remain
times when those injuries themselves, or the 14.4.5 Common Bile Duct,
combination of spleen and other injures, preclude Duodenum, and Pancreas
nonoperative management. In such cases, the
surgeon must consider the risks and benefits of Biliopancreatic injuries can be challenging to
splenic salvage. For surgeons who need to abbre- diagnose and manage. Surgeons should maintain
viate the operation, we recommend splenectomy. a high index of suspicion for these types of inju-
This reduces the likelihood of postoperative ries when wounds are in proximity to the head of
bleeding complications from splenic sources. the pancreas or adjacent structures. Mobilization
The surgeon must also ensure vaccination against of the duodenum, ascending colon, and root of
Streptococcus pneumonia, Haemophilus influ- the small bowel mesentery toward the left upper
enza type B, and Neisseria meningitides during quadrant (Cattell-Braasch maneuver) will expose
the postoperative period. the duodenum and uncinate process of the pan-
creas. The distal common bile duct can be exam-
ined with intraoperative cholangiography
14.4.4 Stomach, Small Intestine, performed through the gall bladder or distal cys-
and Colon tic duct. On occasion, the pancreatic duct can be
enhanced during antegrade cholangiography by
The key concept for managing of hollow visceral applying gentle pressure to the duodenum during
injuries is control of spillage to minimize con- the study (Fig. 14.3). Open cannulation of the
tamination. The surgeon should also make efforts ampulla of Vater with retrograde imaging has
to preserve as much bowel length as possible for also been described; however, the procedure can
definitive reconstruction. Enteral spillage can be be challenging when anatomy has been distorted
controlled in several different ways. Temporary by adjacent trauma. We do not advocate the cre-
suture repair is a fine, as a low profile temporiz- ation of a duodenotomy for the sole purpose of
14  Phase I: Abbreviated Surgery (General Surgery) 153

erature has favored primary repair with a focus

on intraluminal (rather than extraluminal) drain-
age, particularly for low-grade injuries [69].
Definitive management might involve tech-
niques such as triple tube drainage (draining
gastrostomy, draining retrograde duodenos-
tomy, and feeding jejunostomy) or pyloric
exclusion [70–72]. Suture closure of the injury
with nasogastric and perhaps nasoduodenal tube
drainage is sufficient to move the patient back to
the ICU for resuscitation prior to committing to
a particular reconstruction.

14.4.6 Aorta, Cava, and Other

Abdominal Major Vascular
Fig. 14.3  The surgeon’s hand is used to apply pressure Injuries
against the duodenum to occlude the ampulla of Vater and
reflux contrast into the pancreatic duct during antegrade Zone 1 retroperitoneal injuries are best explored
cholangiopancreatography
based on their location relative to the transverse
mesocolon. Lesions above the mesocolon
imaging. These cases are better managed with should be approached by mobilizing the
wide drainage and subsequent imaging with descending colon and splenic flexure toward
MRCP prior to definitive closure. If an injury to the midline. This will expose the celiac axis to
the common bile duct is identified, T-tube drain- the superior mesenteric artery (SMA). Celiac
age is a fast and reasonable procure to minimize arterial injuries are uncommon but carry a
contamination [67]. Extraluminal tube drainage nearly 50% mortality rate [73, 74]. The trifur-
should also be applied. cated nature of the vascular complex makes
Suspected pancreatic injuries, in the absence shunting these injuries nearly impossible.
of other compelling reasons to proceed with lapa- Therefore, patients in extremis should undergo
rotomy, should be evaluated with CT scan, as primary repair or ligation of the celiac axis.
many can be managed without operation [68]. Splenectomy and reimplantation of the splenic
The management of pancreatic injuries found artery to the aorta for retrograde perfusion of a
during laparotomy varies by location and grade. ligated celiac axis have been performed with
Many injuries can be safely treated with hemo- unsatisfactory results.
stasis and aggressive drainage. Injuries distal to The morbidity and mortality of SMA injuries
the neck of the pancreas can be treated with distal is correlated with Fullen zone classification and
pancreatectomy. The timing of this procedure, Organ Injury Scale grade. Wounds to Fullen zone
however, remains at the discretion of the operat- 3 or 4 that are not amenable to repair can be
ing surgeon. Wide drainage with packing might ligated with anticipation of some segmental
be a reasonable option for patients who require bowel ischemia [75]. Injuries that involve Fullen
abbreviated surgery. Similarly, emergent division zone 1 or 2 are better managed with temporary
of the pancreas to access superior mesenteric shunting as these patients generally have other
venous or portal bleeding with planned recon- injuries that need to be addressed prior to mesen-
struction or completion pancreatectomy might be teric vascular reconstruction [76].
required in extreme cases [68]. Hematomas arising from below the transverse
Optimal management of duodenal injuries mesocolon are best exposed with a Cattell-­
remains a controversial topic. Recently, the lit- Braasch maneuver. This includes suspected
154 B.P. Smith et al.

i­ njuries to the iliac vessels. Shunting of abdomi- 14.4.7 Genitourinary System

nal aortic injuries has been described, often-
times, requiring large conduits such as chest The kidney is the most commonly injured part of
tubes. Generally, however, abdominal aortic the GU system, with most resulting from blunt
injuries are more easily managed with definitive mechanisms. Many of these, however, will never
primary repair or patch angioplasty (with syn- come to surgical exploration. Among patients
thetic or ­ biosynthetic materials). Temporary with penetrating mechanisms, however, laparot-
intravascular balloon occlusion is also a useful omy is more common. Bleeding injuries can be
adjunct for hemorrhage control during the initial controlled with vascular control of the renal
exposure. hilum (Fig. 14.5). Whether to obtain vascular
The abdominal inferior vena cava is usually control by taking down Gerota’s fascia laterally
exposed by way of a Cattell-Braasch maneuver. and reflecting the kidney toward the midline or
Direct occlusion of the cava against the vertebral open the retroperitoneum medially adjacent to
bodies/retroperitoneum can be achieved manually the aorta is at the discretion of the operating sur-
or with the help of sponge sticks or formal aortic geon. Some authors have described increased
occlusion devices. Lateral venorraphy is the repair kidney salvage rates with vascular control prior
of choice for major abdominal/pelvic venous vas- to delivery of the kidney; however, these findings
cular injuries. The surgeon should be sure not to are hard to substantiate [77–79].
narrow the vessel to great degrees. The surgeon Among patients with penetrating injuries,
should also consider the possibility of through- nephrectomy occurs in 25–50% of cases. This
and-through-type injuries for larger vessels. On seems more tightly correlated with the degree of
occasion, when mobilization of the back wall is injury rather than surgical approach [80–83].
impossible, anterior injuries will need to be Although many renal wounds do not necessitate
extended to provide intraluminal exposure and
repair of posterior wounds (Fig. 14.4). Many
major abdominal venous injuries can also be
ligated for patients in extremis. Special consider-
ation must be given to the portal and superior mes-
enteric veins, however. As occlusion of hepatic
flow, more importantly, small bowel venous drain-
age can result in devastating consequences.

Fig. 14.4  Extension of an anterior cava injury for ­internal Fig. 14.5  Penetrating kidney injury that is hemostatic
closure of the posterior wound with vascular control
14  Phase I: Abbreviated Surgery (General Surgery) 155

nephrectomy, it might be the best surgical choice 5. Richardson JD, Franklin GA, Lukan JK, et al.
Evolution in the management of hepatic trauma: a 25
for patients who have other sever injuries driving
year perspective. Ann Surg. 2000;232:324–30.
a damage control approach. In these cases, the 6. Winchell RJ, Hoyt DB, Simons RK. Use of com-
surgeon should inspect the contralateral side for puted tomography of the head in the hypotensive
the presence of another kidney. Traditional teach- blunt-­trauma patient. Ann Emerg Med. 1995;25:
737–42.
ing recommends performing an on-table single-­
7. Ordonez CA, Herrera-Escobar JP, Parra MW, et al.
shot intravenous pyelogram to confirm Computed tomography in hemodynamically unstable
functionality of the other kidney; however, this severely injured blunt and penetrating trauma patients.
should not delay lifesaving surgery in the pres- J Trauma Acute Care Surg. 2016;80:597–603.
8. Ball CG, Wyrzykowski AD, Nicholas JM, et al. A
ence of competing priorities.
decades experience with balloon catheter tamponade
Ureteral injures are not life-threatening and for the emergency control of hemorrhage. J Trauma.
can be quickly temporized during abbreviated 2011;70:330–3.
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prevention of acute bleedings in the head and neck
drained and definitely repaired (preferably over a
area with interventional radiology. Head Face Med.
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­primary surgeon is able to stent the injury during 10. Sing RF, Sue SR, Reilly PM. Balloon catheter tam-
the first operation, that is also favorable. Ideally, ponade of exsanguinating facial hemorrhage: a case
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the stent should extend proximally into the renal
11. DuBose JJ, Savage SA, Fabian TC, et al. The

pelvis [84]. Complete injuries should be ligated American Association for the surgery of Trauma pro-
at injury site. Again, definitive management can spective observational vascular injury treatment
be addressed during subsequent operation. If (PROOVIT) registry: multicenter data on modern
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advised. nosis and management of esophageal injuries.
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Trauma Association critical decisions in trauma: pen-
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 Abbreviated Surgery: Orthopaedic
Surgery
15
Roman Pfeifer, Kai Sprengel,
and Hans-Christoph Pape

15.1 Introduction 15.2 V

 alue of Early Orthopaedic
Fracture Fixation
The stepwise approach to the orthopaedic sta-
bilization of the severely injured patient fore- The value of fracture fixation has been empha-
sees manoeuvres to support resuscitation. This sized since the 1970s. Orthopaedic fracture sta-
is achieved by i.v. infusions, coagulatory sup- bilization belongs to the most important tasks
port, vasopressors if required and provid- in the general treatment. It shortens the dura-
ing temporary stabilization and by minimizing tion of the mechanisms addressed in Chap. 15,
the load of surgery. The idea behind it is that such as endocrinologic, humoral and inflamma-
the biological reserve of the patient is main- tory changes [1, 2]. Therefore, as a prerequi-
tained, and the pathogenetic changes induced site, it is important that whenever a patient is in
by trauma are not exaggerated through inade- a good condition, he should undergo any
quate surgeries. It is along the concept of the required surgery:
adage primum non nocere or “do no further Chiefly before trauma care can be improved, the
harm”. reasons for the delay in fracture fixation need to
be answered. One can speculate that the patients
were in shock, were undergoing other more
urgent procedures, or had other injuries being
monitored. However, one can also speculate
many patients had their fracture fixations
delayed due to surgeon or operating room
R. Pfeifer (*) unavailability. Some patients may have required
Department of Trauma and Reconstructive Surgery, “operative clearance” by the system at their
RWTH Aachen University Hospital, institution and this may have provoked a delay
Pauwelsstr. 30, 52074 Aachen, Germany as well. [3]
e-mail: romanpfeifer@aol.com
K. Sprengel In contrast, if an improper selection of the
Department of Orthopaedic Trauma and Harald-Tscherne duration of surgery is performed, the benefits of
Laboratory, University Hospital Zurich, University of fracture fixation can be counteracted [4, 5]. These
Zurich, Ramistr. 100, 8091 Zuerich, Switzerland
patients can lose too much blood, experience a
H.-C. Pape, MD, FACS drop in body temperature and suffer the changes
Professor and Chairman, Department of Trauma,
Zurich University, Raemistr. 100,
associated with these issues, such as exaggerated
8091 Zurich, Switzerland inflammatory reactions and postoperative com-
e-mail: papehc@aol.com plications [6] Table 15.1.

© Springer International Publishing AG 2017 159

H.-C. Pape et al. (eds.), Damage Control Management in the Polytrauma Patient,
DOI 10.1007/978-3-319-52429-0_15
160 R. Pfeifer et al.

Table 15.1  Principles of abbreviated surgical manage- unstable condition. Under these prerequisites, the
ment in the OR
following distribution of patients was observed:
A: General considerations: 80.6% in stable condition, 14.6% borderline
Spend less than 2 h in the OR after haemorrhage patients and 4.8% in unstable condition. Based
control for fixation of fractures
upon these calculations, the abbreviated surgery
Spend as little time as possible if haemorrhage control
cannot be achieved and the patient is in the OR for would apply to about 15% of patients. It has to be
other reasons considered that patients in extremies had been
B: Intra-op principles: excluded by definition.
Core temp.: if dropping, try to correct or terminate In general, the initial polytrauma patient
surgery assessment can be structured according to the
Coagulation: if worsening, try to correct or terminate “four pathophysiological cascades of poly-
surgery
trauma” described above [5]. The parameters of
Ventilation: increased airway pressure, try to find a
cause (pneumothorax) these four cascades to be remembered could be
Need of vasopressors increasing: terminate surgery and summarized in the following phrase: Soft tissue
look for a cause injuries (major extremity fractures, crush inju-
Urinary output decreasing: ries, severe pelvic fractures, lung contusions AIS
> 2), coagulopathy (platelets <90,000) and shock
(systolic BP < 90 mmHg, requirement of vaso-
15.3 C
 alculations on the pressors) contribute to hypothermia (core temp.
Incidence of Abbreviated <33 °C) and are dangerous.
Orthopaedic Surgeries:
The Polytrauma Grading
Score (PTGS) 15.4 S
 election of Patients
for Early Abbreviated
So far, the incidence of abbreviated surgeries has Surgery: Safe Definitive
been based on assumptions of the borderline Surgery Concept
trauma patient and it was assumed to be around
15–20% [5, 7]. Several methods have described regarding a
Our group recently developed a new scoring selection process to determine which patient
system named the PolyTrauma Grading Score should undergo a primary definitive procedure
(PTGS) [6]. It was developed based upon a mul- versus a temporary stabilization followed by
tivariate analysis. It reconfirmed that multiple definitive fixation at a later stage [7]. The safe
prognostic parameters are important. Among definitive surgery concept encompasses both
them are the admission blood pressure, acid base components from early definitive surgery and
abnormalities [7], coagulopathy, the number of damage control. Its prerequisite is to go to the
pBRCs administered and the injury severity score operating room, if required by the injury pattern,
(Table 15.2). We differentiated certain target and perform the appropriate type of surgery
mortality rates based upon the new definition of according to the criteria listed in Table 15.2. Safe
polytrauma (15%, 30%, 45%). Based on the ini- definitive surgery implies the four cascades of
tial definition of target mortality rates for low polytrauma and puts special emphasis on respect-
(mortality, 5%)-, intermediate (mortality, 15%)- ing lung function, coagulation, temperature and
and high-risk groups (40%), stable patients were acid base changes (Fig. 15.1).
defined by a score value of up to 5 points. Patients Specific prognostic criteria have been devel-
with a score value between 6 and 11 points were oped to minimize the systemic risks depending
therefore found to be in a borderline condition; on the current physiologic/immunologic state of
more than 11 points were associated with an the individual patient [8].
15  Abbreviated Surgery: Orthopaedic Surgery 161

Table 15.2  Logistic regression model to evaluate the impact of risk factors to develop a scoring system (n = 5,988
patients)
95% confidence
Predictor Regression coefficient Odds ratio (OR) interval (95%-CI) p-value
BP 76–90 mmHg 0.249 1.283 0.962–1.712 0.09
BP < 75 mmHg 0.642 1.889 1.398–2.580 <0.001
Base deficit 8–10 0.474 1.606 1.119–2.304 0.01
Base deficit >10 1.251 3.371 2.553–4.453 <0.001
INR 1.4–2.0 0.160 1.174 0.897–1.536 0.24
INR > 2.0 0.899 2.457 1.754–3.442 <0.001
NISS 35–49 0.900 2.460 1.916–3.157 <0.001
NISS 50–75 1.188 3.279 2.487–4.324 <0.001
pRBCs 3–14 0.671 1.957 1.514–2.529 <0.001
pRBCs > 15 1.692 5.430 3.910–7.539 <0.001
Platelets <150,000 0.555 1.743 1.383–2.196 <0.001
constant −3.867 – – <0.001
From Hildebrand et al. [26]
Parameters graduated as low risk (Table 2) were set as categorical reference group

Knowledge of treatment algorithms is of para- ations, without assessing any other parameters.
mount importance to avoid distraction from occult We feel that this is a dangerous approach since
problems. A pertinent example would be neglect of lactate by itself can be influenced by many other
intra-abdominal exsanguination while attempting parameters, and it does not allow for safe defini-
to deal with severe extremity injuries. The trauma tive surgery [10, 11]. However, there is a contri-
team has to quickly ascertain the extent of the bution of various metabolites to the “unmeasured”
injury as well as assess the pulmonary and haemo- anions in critically ill patients with metabolic aci-
dynamic status of the patient. Standardized diag- dosis [12]. Also, patients that do not have altered
nostic and operative tactics should be applied and lactate values may demonstrate severe lung
coordinated to avoid mistakes that could impact ­contusions or may be on medications that cause
negatively on the patient’s prognosis. During the elevaled lactate levels. Moreover, along with an
course of treatment, the clinical scenario can increasing number of patients that undergo acute
change rapidly and management plans must able to injuries in their later stages of life, chronic dis-
adapt accordingly. Therefore, the clinical judge- eases, such as renal failure, can occur and may be
ment of the patient’s condition is crucial. the reason for seemingly patholigical lactate val-
The use of markers of occult tissue hypoper­ ues [13]. Finally, many elderly patients are on
fusion, such as serum lactate, to demonstrate Coumadin for medical reasons. In these, it would
­adequacy of resuscitation has become a common- also be unwise to only look at lactate levels for
place, and the measurement of inflammatory medical clearance.
markers that highlight patients at risk is helpful in In this line, an international group of authors
deciding which patients are best served by dam- used the similar principles to develop an
age control surgery. Most recently, orthopaedic evidence-­based definition of polytrauma. In addi-
surgeons from Cleveland, (Ohio) proposed to use tion to a minimum of two significant (AIS 2 or
solely parameters associated with the acid base greater) injuries, several cofactors were calcu-
system only universally for virtually all patients lated on the basis of the registry. These were
with fractures [9]. They discuss that normaliza- associated with a raise in the mortality rates
tion of base excess and lactate values allows from about 12–15% (ISS > 16) to about 40%.
patients to be cleared for major orthopaedic oper- Five independent physiologic variables were
162 R. Pfeifer et al.

Safe Definitive Surgery

(Dynamic approach for the severely injured patient)
Multiple Trauma Patient

Primary
Assessment Borderline Unstable In extremis
(in the ER)

Assess:
Lung Function RESUSCITATION RESUSCITATION AND
Temperature Multiple Endpoints or EAC protocol SURGICAL HEMORRHAGE
Shock CONTROL
Coagulopathy
Monitoring:
Lung Function
Temperature
Secondary Fluid Requirement
Stable Borderline Unstable
Assessment Coagulopathy
(prior to surgery)

DCO / traction
DAY 1 SDS DCO

RE–Assessment:
Coagulation, fluid balance,
Tertiary vasopressor need, lung function
Assessment
(e.g. 24 h post-
trauma)
Stable Borderline

repeated
DAILY reevaluations

Assessment

Definitive surgery once stabilized

SDS

Fig. 15.1  Inclusive protocol of tapered early surgery for is designed to combine the positive effects of early frac-
orthopaedic injuries in polytrauma patients. It is of note ture stabilization and early temporary surgery, depending
that all stable patients are excluded as their treatment is on the patient condition [22]
considered to be early fracture stabilization. This concept

identified, and their individual cutoff values were ≥6.0), coagulopathy (international normalized
calculated based on a set mortality rate of 30%: ratio 1.4/partial thromboplastin time >40 s) and
hypotension (systolic blood pressure <90 mm age (>70 years). This study supports the idea of
Hg), level of consciousness (Glasgow Coma multiple factors to be required for the assessment
Scale [GCS] score <8), acidosis (base excess of a multiply injured patient [14].
15  Abbreviated Surgery: Orthopaedic Surgery 163

It has also been suggested that patients at risk of ciated with a high risk of adverse outcomes,
adverse outcome, such as those with head injury, systolic blood pressure 76–90 mmHg, INR
bilateral lung contusions, multiple long bone inju- 1.4–2, thrombocytes, base deficit 8–10, NISS
ries, coagulopathy, hypothermia or estimated 35–39 and pBRC 3–14
operation time of >6 h, should be considered for
sequential staged surgical management [15]. These appear to be among the factors govern-
Markers of the adequacy of shock reversal, such as ing which line of treatment should be used in
serum lactate, are measured routinely in trauma patients with polytrauma.
centers. It is therefore easy to envisage the routine Several guides to treatment have been devel-
use of markers of pro- and a­ nti-­inflammatory sys- oped especially for the management of fractures of
tems such as IL-6, IL-10 and procalcitonin to aid the long bones and pelvis [22]. Additional clinical
in the decision to carry out damage control sur- criteria that we have been used as a basis for shift-
gery. Delaying definitive surgery until the shock ing to damage control orthopaedics include a pH
state is fully reversed would appear to be not only of <7.24, a temperature of <35 °C, operative times
beneficial but imperative [8]. of more than 90 min, coagulopathy and transfu-
Many trauma scoring systems (e.g. the abbre- sion of more than ten units of packed red blood
viated injury scale [16] injury severity score cells. Furthermore, certain specific orthopaedic
[17], revised trauma score [18, 19] and Glasgow injury complexes appear to be more amenable to
Coma Scale [20] have been developed in an damage control orthopaedics; these include, for
attempt to describe the overall condition of the example, femoral fractures in a multiply injured
trauma patient. Bosse et al. [21] noted that “there patient, pelvic ring injuries with exsanguinating
is no score that assists in decision-making during haemorrhage and polytrauma in a geriatric patient.
the acute resuscitation phase”. This idea sup-
ports the notion that one should not rely exclu-
sively on a single parameter, but rather a 15.5 S
 trategies and Technical
combination of parameters that should cover Aspects During Abbreviated
several pathophysiological pathways [5]. Most Surgery
of the components are scores that have been rou-
tinely used in the past and are widely accepted. 15.5.1 Absence of Chest Injuries
For screening purposes, the following threshold and Long Bone Fractures
levels have been used:
The following scenario, depending on the sever-
• Pulmonary dysfunction (PaO2/FiO2 <250) ity of chest injury for patients with long bone
• Platelet count (<95,000) fractures (femur and tibia), has been advocated:
• Hypotension unresponsive to therapy In patients without thoracic trauma that
• >10 blood units transfused per 6 h respond adequately to resuscitation, all major
• Requirement for vasopressors fractures are stabilized, as long as the patient is
stable during the surgeries. A new assessment of
These recommendations are underlined by the parameters applies intraoperatively. In patients
PolyTrauma Grading Score (PTGS), as the score with thoracic trauma with an AIS of 2–4 points
is the result of deductive calculations from a (“borderline patient”), unreamed nailing is per-
nationwide database [8]. formed to minimize the potential risk of acute fat
In this score, the following factors are embolization. In patients in a critical condition
crucial: (haemodynamically unstable) or with associated
severe thoracic trauma (AIS >4 points), intra-
• Severity of the injuries sustained medullary stabilization is avoided, and a tempo-
• Presence or absence of a criterion indicating rary external fixateur is applied until the
borderline status and associated factors asso- pulmonary situation has stabilized. Additional
164 R. Pfeifer et al.

clinical criteria as a basis for shifting to damage the assessment of trauma patients is superior to
control orthopaedics include coagulopathy, a pH using just one. For thoracic trauma, it was the oxy-
of <7.24, pathological lactate, a temperature of genation, number of rib fractures, degree of paren-
<35 °C, planned operative times of more than 2 h chymal contusion, presence of pleural involvement
and transfusion of more than ten units of packed and patient age. ROC a­nalysis clearly indicated
red blood cells. that the combination, as used in the TTS, was
superior to ISS and AIS chest alone [3].

15.5.2 Presence of Chest Injury

for the Indication 15.5.3 Ipsilateral Femoral and Tibial
of Abbreviated Surgery Shaft Fractures

The assessment of pulmonary function requires In stable patients, all fractures are stabilized dur-
special attention: The progressive nature of a pul- ing the same initial operation (Table 15.3). If the
monary contusion can be problematic and is patient is in questionable state and improves, one
frequently underestimated. Early after injury, the long bone fracture is stabilized definitely accord-
blood gas parameters can still be within normal ing to the surgeon’s preference or the degree of
limits, and the chest radiograph may be negative. soft tissue injury. If the patient then deteriorates,
Signs of deterioration of pulmonary function the second and following fractures can be stabi-
include: lized by external fixation or traction.

• Presence of a lung contusion on the initial

chest radiograph or CT scan 15.5.4 Pelvic Trauma and Packing
• Worsening oxygenation reflected in an
increased FiO2 >40% or PaO2/FiO2 <250 Pelvic fracture is often seen in conjunction with
• Increased airway pressures (e.g. >25–30 cm multisystem trauma and can lead to rapid occult
H2O) haemorrhage. Treatment should be conceived as
part of the resuscitative effort and early interven-
Chest trauma is an independent parameter of tion can be life-saving. Bleeding is ­commonly
outcome [23]. Along with the improvement in from multiple small sites rather than injured
diagnostics, more sophisticated diagnoses of major vessels and, due to the large v­ olume of the
parenchymal pulmonary changes were an option. retroperitoneum, in severe cases spontaneous
Therefore, scores for quantification of the degree arrest is unlikely. Furthermore, it is common for
of chest injury were developed [24, 25]. It became the retroperitoneum to be breached during the
evident that the use of combined parameters for injury further decreasing barriers to the ongoing

Table 15.3  Staged management of ipsilateral femoral and tibial fractures

Admission
condition Stable Borderline Critical Comments
Resuscitation +++ (responder) −−−responder Spanning
response ex.fix.
Day 1 surgery Femur Femur retrograde Femur ex.fix
retrograde tibia Tibia antegr./ex.fix. Tibia ex.fix.
antegrade
Secondary Femur retrograde
conversion
15  Abbreviated Surgery: Orthopaedic Surgery 165

haematoma expansion. Treatment with the pneu- ­ echanisms triggered by profound shock,
m
matic antishock garment or pelvic belt-straps exsanguination, acidosis, hypothermia and
­
can give some temporary stabilization, but coagulopathy. Delays in the decision to per-
results are inconclusive, and severe complica- form damage control contribute to a higher
tions have been reported in relation to their use. morbidity and mortality. Therefore, damage
There has been increasing interest in the use control is a vital part of the management of the
of selective angiography in these cases to embo- multiply injured patient and should be per-
lize bleeding vessels. However, this intervention formed before metabolic exhaustion.
requires a full set-up of a level I trauma center, Damage control orthopaedics is ideal for an
and even in these, it is often time consuming. unstable patient or a patient in extremis, and it
Patients must be relatively stable and careful has some utility for the borderline patient as
selection is crucial. Embolization is an adjunct well. Specific injury complexes for which
where continued arterial haemorrhage is sus- damage control orthopaedics should be con-
pected. In severe injuries with profound haemo- sidered are femoral fractures (especially bilat-
dynamic instability, external fixation, pelvic eral fractures), pelvic ring injuries with
C-clamp and open tamponade by packing are profound haemorrhage and multiple injuries in
performed in many European centers and in some elderly patients. Specific subgroups of multi-
in the USA. In these, it is often combined using a ply injured orthopaedic patients who may ben-
C-clamp. In vertical pelvic instability (C-type efit from damage control orthopaedics are
injury), the lower extremity of the respective those with a head injury, chest trauma or a
should be accessible for better ease of reduction. mangled limb. A limited form of damage con-
Following application of external fixation trol orthopaedics (limb damage control ortho-
devices, if there is prior evidence of free intra- paedics) is a rational alternative for the
peritoneal fluid, a midline laparotomy should be treatment of isolated, complex limb injuries.
performed and the intra-abdominal organs exam- Clinical data and emerging discoveries in
ined for bleeding following standard manage- molecular medicine may continue to provide
ment protocols for blunt abdominal trauma. In answers to the question of when orthopaedic
the absence of intra-abdominal injury, the atten- surgeons should use a damage control ortho-
tion should be directed to the retroperitoneum. paedics approach.
Following skin incision, ruptured pelvic soft tis- Whatever approach is taken, it is clear that
sues are usually readily visible. After evacuation the management of patients with multiple
of haematoma, the packing is performed using injuries must pay close attention to the sys-
lap sponges in meander technique. temic effects of the respective procedure and
timing. This process of decision-making may
Conclusions be defined as “injury-­ patient tailored” for
The polytrauma trauma patient who requires damage control orthopaedics. However, with
massive transfusion incurs the greatest risk for regard to this strategy, it remains necessary to
the multifactorial interactions between acido- prospectively define and validate prognostic
sis, hypothermia, and coagulopathy and soft criteria performing studies similar to the
tissue injuries. There continues to be an ongo- Lower Extremity Assessment Project which
ing challenge to identify better predictors of should be fulfilled to better understand the
outcome, improved means of resuscitation, role of damage control orthopaedics in the
greater understanding of physiologic derange- treatment of patients who have sustained
ments and better timing to institute damage orthopaedic trauma, especially those with
control. There also remains a need to better concomitant injuries to the chest and head
understand the cellular and subcellular (Table 15.4).
166 R. Pfeifer et al.

Table 15.4  Case example for abbreviated initial surgery

Injury Day 1 Day 3 Day 7 Day 15 Day 20 Day 34

Blunt chest trauma Vent Vent Vent Vent Vent

TTS score:

Pelvic hemorrhage Laparotomy, Second ORIF

packing look

Large bowel laceration Resection,

Hartman

C type pelvic fx. Ex.fix ORIF

plating Rehab

L fem shaft frx (open) Ex fix, vac amputat Vac Vac Vac
ion

R fem shaft fx. EX. Fix. IMN

R patella frx (open) Partial - - - -

resection

R prox tibia Frx (open) Ex fix, Vac Vac Vac Vac IMN, local
flap

Duration of surgery: all 2.5 h 2h 45 min 4h 2h 9h

Duration of surgery: 40 min.

Ortho

Immunologic markers

IL-6 (ng/L) 3,210 1,507 60.4 22.3 Normal range < 5,4

IL-8 (ng/L) 2,900 64,4 22.4 <5 Normal range <62

IL-1 beta interleukin-1 beta, IL-6 interleukin-6, IL-8 interleukin-8, Amp amputation, DFN distal femoral nail,
DHS dynamic hip screw, dist distal, ex fix external fixation, extub extubation, fem femoral, flap myocutaneous skin flap,
fx fracture, hum humerus, ORIF open reduction and internal fixation, prox proximal, reconstr reconstruction,
­reosteosynth reosteosynthesis, tib tibial, vac wound vac, vent ventilation, UTN unreamed tibial nail
15  Abbreviated Surgery: Orthopaedic Surgery 167

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 ICU Care Following Damage
Control Surgery
16
Constance W. Lee, Phillip A. Efron,
and Frederick A. Moore

16.1 Introduction from anesthesia. Ventilator asynchrony increases

intrathoracic pressure and can decrease venous
Damage control surgery (DCS) has radically return in hypovolemic patients and thereby com-
changed our surgical approach to critically ill promise cardiac function at a time when optimiz-
patients who arrive with severe bleeding. The pri- ing oxygen delivery (DO2) is paramount to
mary goals of DCS are to expedite operative reversing shock. Furthermore, increased work of
interventions, to minimize ongoing physiologic breathing can substantially increase oxygen con-
derangements, and to prevent early deaths from sumption (VO2), exacerbating the difference
exsanguination and refractory shock. The pur- between DO2 and VO2. The optimal mode of
pose of this chapter is to discuss the ICU care mechanical ventilation for DCS patients contin-
after DCS that is needed to reverse physiologic ues to be debated. Initially we provide full venti-
derangements and prepare the patient for a sec- lator support with the assist control mode using a
ond operation where definitive operative treat- low inspiratory time/expiratory time (I/E) ratio to
ment will be rendered. minimize the auto-PEEP that can occur as the
patient awakens. In addition, it increases this
ventilator mode which allows increased respira-
16.2 Mechanical Ventilation tory rates to expire the increased CO2 production
that occurs with effective resuscitation. After ini-
Typically DCS patients arrive to the ICU on a tial volume resuscitation, low levels of PEEP are
mechanical ventilator under the effects of general prophylactically applied to maintain functional
anesthesia. Sufficient analgesia and sedation residual capacity. Higher-level PEEP can be used
should be instituted so the patients are not to therapeutically increase mean airway pressure
discordant with the ventilator as they recover
­ to promote oxygenation in patients with high
FIO2 requirements [1]. In patients with ongoing
hypoxia despite high PEEP, we convert to a pres-
sure control mode utilizing protective low tidal
C.W. Lee, MD • P.A. Efron, MD volumes, moderate PEEP levels, and increased
F.A. Moore, MD (*) I/E ratio to allow optimized higher mean airway
Department of Surgery, Division of Acute Care
Surgery and Surgical Critical Care, University of pressures while limiting peak airway pressures.
Florida, Gainesville, FL, USA Neuromuscular blockade is initiated in refractory
e-mail: Constance.Lee@surgery.ufl.edu; hypoxia to further limit ventilator asynchrony,
Phillip.Efron@surgery.ufl.edu; protect the lung, and prevent acute respiratory
Frederick.Moore@surgery.ufl.edu

© Springer International Publishing AG 2017 169

H.-C. Pape et al. (eds.), Damage Control Management in the Polytrauma Patient,
DOI 10.1007/978-3-319-52429-0_16
170 C.W. Lee et al.

distress syndrome (ARDS). Early use of cisatra- the mid-1990s, surgical intensivists at the
curium in severe ARDS has been demonstrated University of Texas-Houston (UT-Houston)
in a multicenter prospective randomized con- developed a computerized clinical decision sup-
trolled trial (PRCT) to improve survival and ven- port (CCDS) protocol that utilized PAC-derived
tilator liberation without increasing muscle data to direct ICU resuscitation in trauma
weakness [2]. Interestingly, earlier PRCTs testing patients after severe bleeding. The protocol goal
cisatracurium in ARDS demonstrated that it also was to maintain DO2 to >600 mL/min/m2 for
reduced systemic pro-inflammatory cytokine lev- 24 h using five sequential algorithms for inter-
els, suggesting that it can reduce biotrauma- ventions: (1) transfuse packed red blood cells
induced remote organ injury [3]. While early (PRBCs) if the patient’s hemoglobin [Hgb]
prone positioning in patients with severe ARDS <10 g/dL; (2) volume loading with Lactated
has been shown in a recent multicenter PRCT to Ringer’s (LR) if the patient’s pulmonary capil-
decrease mortality, we rarely utilize it early after lary wedge pressure (PCWP) <15 mm Hg; (3)
DCS because severe ARDS usually occurs later bolus with normal saline (NS) to optimize
in the clinical course [4, 5]. CI-PCWP (i.e., create a “Starling curve”) if the
patient’s Hgb ≥10, PCWP ≥15, and DO2I <600;
(4) infuse dobutamine if the patient’s [Hgb]
16.3 Resuscitation ≥10, PCWP ≥15, and DO2I <600; and (5)
infuse norepinephrine if the patient’s mean arte-
16.3.1 End Points rial pressure (MAP) <65 mm Hg. It was
observed that most patients responded quite
Intensive care unit (ICU) resuscitation is a key favorably to the initial interventions of PRBC
intervention after DCS, and the primary goal of transfusion and volume loading and easily met
this resuscitation is to increase DO2 to reverse the DO2 goal. However, roughly 15% of patients
shock. In the 1980s, Shoemaker and colleagues were nonresponders. Some had ongoing bleed-
observed that survivors after shock became ing that required a hemorrhage control interven-
hyperdynamic increasing their DO2 to >600 mL/ tion, but most nonresponders had persistent low
min/m2, cardiac indexes (CIs) to >4.5 L/min/m2, CIs and high systemic vascular resistances.
and VO2 to >150 mL/min/m2 [6]. They proposed With ongoing volume loading proceeding
that these “supranormal” values be the resusci- through the “Starling curve” intervention, these
tation goals for high-risk patients to reverse nonresponders developed problematic tissue
shock and early PRCTs supported this practice. edema in the lungs (i.e., fulminant acute lung
In the late 1980s, with the widespread availabil- injury) and the gut (i.e., ACS). This information
ity of pulmonary artery catheters (PACs) capa- prompted a decrease in the DO2 goal in the
ble of continuously measuring mixed venous CCDS logic to therapeutic, rather suprathera-
hemoglobin saturation (SvO2), many surgical peutic, levels (i.e., 450 ml/mL/min/m2).
intensivists presumptively placed PACs in high- Subsequently, it was observed that these patients
risk patients to monitor oxygen transport vari- had significantly less ACS, multiple organ fail-
ables and maximized DO2 in an attempt to ure (MOF), and deaths as compared to those
eliminate unrecognized flow-dependent resuscitated to a supranormal DO2 goal. As a
impaired VO2. By the early 1990s, supranormal result, by the mid-2000s, the use of PACs
DO2 resuscitation became standard of care. decreased dramatically, and a variety of alterna-
However, as the 1990s evolved, PRCTs testing tive monitors were promoted to replace PACs.
supranormal DO2 resuscitation could not con- This fueled an ongoing debate over optimal end
firm this to be beneficial, and some studies points of resuscitation that has yet to be resolved.
showed it to be harmful [7]. During this time In the UT-Houston, CCDS logic has been
period, abdominal compartment syndrome updated and currently uses central venous pres-
(ACS) emerged as an epidemic after DCS. In sure (CVP) as the initial indicator of volume
16  ICU Care Following Damage Control Surgery 171

status. The early goals of resuscitation are (1) tifying the nonresponder who needs alternative
CVP of 10 to 15 cm H20, (2) mean arterial pres- interventions and will be harmed by ongoing
sure (MAP) of ≥65 mm Hg, (3) [Hgb] ≥8 g/dL, unbridled resuscitation efforts.
(4) urine output of ≥0.5 ml/kg/h, and (5) central
venous oxygen saturation (ScvO2) of ≥70%. If
the patient is resuscitated into the CVP range 16.3.2 Crystalloid Versus  Colloid
and there is need for ongoing interventions, Debate
bedside echocardiography is performed to
assess volume status and ventricular function Based on convincing experimental data in the
with the goal of optimizing cardiac performance 1960s, isotonic crystalloids became standard of
[8]. Transthoracic and transesophageal echocar- care in resuscitation during the Vietnam conflict
diography is being utilized in the ICU setting to [16, 17]. For various reasons, early mortality
determine a patient’s cardiac index and volume decreased, but a new entity called “shock lung”
status as well as follow a patient’s response to emerged as a major cause of late deaths. This
resuscitation [9, 10]. The cardiac index and cen- complication was soon described in civilian pub-
tral venous pressure estimates obtained with lications as ARDS and was illustrated to be the
ultrasound have been demonstrated to correlate major source of morbidity and mortality in the
well with estimates from a pulmonary artery ICU. Since the pathogenesis was not understood,
catheter [11]. Recent studies suggest that lactate controversy emerged over whether ARDS was an
clearance is a superior end point for resuscita- iatrogenic complication of isotonic crystalloids.
tion compared to the above described goal- Over the ensuing years, numerous PRCTs com-
directed therapy [12]. An elevated lactate level paring crystalloids to colloid use in resuscitation
occurs when there is a shift to anaerobic metab- have displayed no consistent differences in the
olism and lactate levels decrease with effective incidence of ARDS or mortality. These results
resuscitation. However, it has repeatedly been are supported in numerous meta-analyses and by
observed that a persistent high lactate despite the recently published SAFE (Saline vs. Albumin
aggressive resuscitation is a strong predictor of Fluid Evaluation) and ALBIOS (Albumin Italian
MOF and mortality [13]. This may not be due to Outcome Sepsis) PRCTs [18, 19]. Given the
inadequate DO2 but rather due to dysfunctional markedly increased costs of colloids, it is diffi-
mitochondria, which is referred to as tissue dys- cult to justify their routine use. However, a series
oxia [14]. Unfortunately, we currently do not of studies looking at the clinical presentation of
have any therapies to reverse mitochondrial ACS after shock resuscitation indicated that early
dysfunction [15]. Other monitored variables excessive crystalloids play a key pathogenic role.
that have been proposed as resuscitation end Large-volume crystalloid resuscitation can limit
points include gastric mucosal interstitial PCO2 the diffusion of oxygen and nutrients across an
(PgCO2), as measured by gastric tonometry, and edematous interstitial space [20]. In addition, it
tissue hemoglobin oxygen saturation (StO2), as can cause intracellular edema with reduction in
measured by near-infrared spectroscopy. These intracellular efficiency and poor glucose regula-
variables have been extensively studied in shock tion [21], as well as causing the release of inflam-
resuscitation, and persistent abnormal values matory cytokines and increasing organ
are predictive of MOF and death. However, cor- dysfunction [22]. The endothelial glycocalyx is a
rection of these abnormalities has not been dem- complex of plasma proteins, glycosaminogly-
onstrated to improve patient outcomes. Given cans, and proteoglycans that is necessary for
the added expense of these monitors, they have maintaining endothelial osmotic integrity. Both
not been adopted for this indication [13]. In hemorrhagic shock and crystalloid resuscitation
summary, resuscitation is a key intervention, but can result in thinning of the endothelial glycoca-
the optimal end points remain unclear. A resus- lyx, which leads to intravascular volume deple-
citation protocol, however, is important in iden- tion, and the need for continued resuscitation [23,
172 C.W. Lee et al.

24]. Crystalloid resuscitation can induce pulmo- and has what some consider more “physiologic”
nary edema and acute lung injury [23, 25, 26] and electrolyte concentrations [31]. Limited experi-
has been associated with arrhythmias and a lower mental data indicate that LR and Plasmalyte
than expected cardiac output [27]. Aggressive restored volume and correct electrolyte and acid-­
crystalloid resuscitation can result in bowel wall base deficits equally well [32]. However, there is
edema, causing relative tissue ischemia second- the concern that the magnesium may counteract
ary to a longer oxygen diffusion distance, and the vasoconstrictive response to hypovolemia and
increased risk of abdominal compartment syn- thereby increase mortality in severe hemorrhagic
drome [28, 29]. Combined, all of this evidence shock [31].
provides the rationale for the use of colloids in
DCS patients who have received a large volume
of crystalloids. In our ICU resuscitation, we use 16.3.4 Blood Transfusions
albumin boluses after 6 l of crystalloid adminis-
tration. An interesting footnote in the crystalloid In the past, a [Hgb] of 10 g/dL was believed to be
vs. colloid debate is the use of hydroxyethyl the optimal level in critically ill patients.
starches (HES). In 2011, PRCTs by Joachim However, PRBC transfusions have been shown to
Boldt, MD, testing HES were retracted because be a strong independent risk factor for adverse
of research misconduct. A more recent system- outcomes (including infections, MOF, and
atic review (excluding these studies) convinc- deaths) across a broad spectrum of high-risk hos-
ingly showed that HES is associated with pitalized patients [33]. Additionally, there are a
increased AKI and mortality. As a result HES number of plausible mechanisms to explain these
should not be used in shock resuscitation. It adverse outcomes including suppression of cell-­
should also be known that HES has a US Food mediated immunity, elaboration of pro-­
and Drug Administration (FDA) black box inflammatory mediators that provoke neutrophil
warning. cytotoxicity, and decreased RBC deformity that
impairs microvascular perfusion. As a result of
concerns over potential harm, consensus panels
16.3.3 Type of Crystalloids lowered recommended level to a [Hgb] of >7 g/
dL. This recommendation is supported by a
LR solution is preferable to NS because it pro- recent PRCT where ICU patients randomized to
vides a better buffer for metabolic acidosis, and restrictive blood transfusions (transfuse if [Hgb]
large-volume NS causes a hyperchloremic acido- <7 g/dL and maintain between 7 and 9 g/dL) did
sis, but to date clinical experience has not docu- as well and possibly better than patients who
mented any differences in mortality between were liberally transfused (transfuse if <10 g/dL
LR- and NS-based resuscitation. Recent studies and maintain between 10 and 12 g/dL). The
have suggested that NS induces hyperchloremia choice of transfusion trigger is dependent on the
that causes AKI, but a recent PRCT failed to clinical scenario. During active shock resuscita-
prove this supposition [30]. However, NS is pre- tion with ongoing bleeding, maintaining for a
ferred in patients with obvious traumatic brain higher [Hgb] is preferred. Blood is a good vol-
injury because it has a higher osmolarity and thus ume expander and will thus limit crystalloid infu-
reduces cerebral edema. Additionally, NS is used sions, and the higher [Hgb] provides a margin of
when blood is being transfused because theoreti- safety, and higher [Hgb] levels may promote
cally the calcium in LR could exceed the chelat- hemostasis. By our CCDS logic, we initially
ing capabilities of the citrate in the stored blood, maintain [Hgb] >8 g/dL, and once bleeding is
resulting in the formation of clots that could enter controlled, the transfusion trigger is lowered to
the circulation and compromise the microcircula- 7 g/dL unless there is evidence of high oxygen
tion. Plasmalyte is an alternative isotonic crystal- extraction (i.e., ScvO2<70%) in which case addi-
loid that contains magnesium instead of calcium tional transfusion is warranted.
16  ICU Care Following Damage Control Surgery 173

16.4 Correction of Coagulopathy thermia affects a platelet’s ability to produce

thromboxane B2, causing a prolongation of
In the early 1980s, it was recognized that a sub- bleeding time [47]. The liver and spleen seques-
stantial number of trauma patients with severe ter platelets in the setting of hypothermia [48].
bleeding often died despite operative repair/con- Trauma porcine models have demonstrated that
trol from ongoing coagulopathic bleeding caused hypothermia does inhibit clot formation time and
by the “bloody vicious cycle” of acidosis, hypo- clotting time, but does not impair maximum clot
thermia, and coagulopathy. This recognition coin- firmness [41, 49]. Coagulopathy will persist
cided with the seminal report by Harlan Stone in despite transfusion to an adequate platelet count
1982 in which he first described the principles of if the hypothermia remains uncorrected [50].
DCS in patients found to have coagulopathic Coagulopathy associated with hypothermia will
bleeding during emergency laparotomies. These not manifest as prolongation of prothrombin time
reports spurred intense investigation into under- (PT) and activated partial thromboplastin time
standing and treating trauma-induced coagulopa- (APTT) because these laboratory tests are per-
thy (TIC). Unfortunately, the exact pathogenesis formed with the sample warmed to 37 °C and so
of the TIC remains elusive and is beyond the do not demonstrate coagulopathy in a hypother-
scope of this discussion. However, by the late mic patient [38, 51]. Experimental work and sub-
1990s, it was recognized that critically injured sequent clinical observations indicated that ratios
patients arrive coagulopathic at the trauma center of FFP to RBC <1:2 were warranted to avoid fac-
(TC) and that most of the deaths from exsangui- tor deficiency, but platelets were not justified
nation occur within the first 6 h. These data pro- with initial PRBC transfusion. Recently, the mili-
vided the rationale for starting massive transfusion tary has promulgated a preemptive platelet to
protocols (MTPs) very soon after TC arrival. FFP to RBC ratio of 1:1:1 based on the argument
Trauma-induced or trauma-associated coagu- that this represents the composition of shed
lopathy may be seen in 25–41% of trauma whole blood. The debate over the optimal ratio of
patients on arrival to the hospital [34–36]. components in empiric MTPs is still ongoing and
Trauma-induced coagulopathy may be caused by is not pertinent to this discussion because in the
endothelial cell injury, a platelet defect, depletion ICU after DCS blood components should be
of platelets and coagulation factors (depletion of guided by laboratory determinations. This
factors I, II, V, VII, VIII, IX, and X), and an emphasizes the need for a rapid comprehensive
expenditure of platelets and factors in hyperfibri- assessment of coagulation which thromboelas-
nolysis or disseminated intravascular coagulation tography (TEG) provides. This technology of
[34, 37–39]. TIC has been associated with a poor real-time viscoelastic analysis of blood clotting
prognosis, including increased incidence of mul- assesses clot strength from the time of initial
tiple organ failure and death [35, 40]. A bleeding fibrin formation to clot retraction, ending in fibri-
trauma patient may have the immediate trauma-­ nolysis. In contrast, the standard battery of coag-
induced coagulopathy compounded by the devel- ulation studies (PT, PTT, and bleeding time) is
opment of a consumptive coagulopathy. Porcine based on isolated, static end points. Rapid TEG is
trauma models have demonstrated that hemor- further advantageous as the addition of tissue fac-
rhage impairs clot strength [41]. The develop- tor to the whole blood specimen stimulates a
ment of an immediate coagulopathy has also rapid reaction. The resulting coagulation tracing
been associated with traumatic brain injury [42]. can be transmitted to the ICU as a functional pro-
Hypothermia negatively affects the coagula- file graphic within 5 min of blood sampling. This
tion system. Factors XI and XII have been dem- point-of-care monitoring offers near real-time
onstrated to be less effective at 35 °C [43]. determination of the impact that specific compo-
Hypothermia has been demonstrated to both nent therapy is having on coagulation. TEG goal-­
induce and decrease platelet activation [44–46]. directed hemostatic therapy has become the
Valeri and associates demonstrated that hypo- standard of care in MTP resuscitation in many
174 C.W. Lee et al.

trauma centers, and clinical studies have shown cardiac dysrhythmias. Additionally, it is a strong
that it can significantly reduce unnecessary blood predictor for adverse outcomes including MOF,
component therapy [52]. prolonged ICU stays, and death. Unfortunately,
reversing hypothermia during active shock of a
DCS patient is quite difficult; therefore, the focus
16.4.1 Recombinant Factor VIIa needs to be on prevention. This starts in the emer-
(rFVIIa) gency department with placement of a urinary
catheter that can monitor temperature (T). After
Recombinant factor VIIa (rFVIIa) is currently initial trauma evaluation is complete, the exposed
licensed for treatment of patients with congenital body is covered with warmed blankets, and fluids
factor VII deficiency and patients with hemo- and blood products are infused via fluid warming
philia and inhibitory autoantibodies. However, it devices (e.g., Level I fluid infuser). Initiation of
has been used off-label for the prevention and warming strategies that begin preoperatively is
treatment of bleeding in patients without congen- more effective [58, 59]. In the operating room, the
ital factor VII deficiency or hemophilia. A recent room is warmed, forced warm air blankets are
Cochrane review assessed randomized controlled applied, the head is covered with a heat reflecting
trials comparing rFVIIa to placebo or comparing cap, and mechanical ventilation is provided with
different doses of rFVIIa, including trials that uti- warm (38 °C), humidified air. Patients who
lized rFVIIa as a prophylactic agent or as a thera- received warmed intravenous fluid maintained
peutic agent. The final assessment was that data their core temperature approximately 0.5 °C
was not sufficient to prove the effectiveness of higher than patients’ given room temperature
rFVIIa as a general hemostasis drug [53]. intravenous fluids [60]. Forced-air warming
maintains core temperature approximately
0.5–1 °C higher than extra thermal insulation
16.4.2 Tranexamic Acid (TXA) [61]. However, if the forced-air warming blanket
becomes wet, it will inadvertently cool the patient
Hyperfibrinolysis has been associated with [62]. Humidifying and warming the inspired
increased mortality [54]. Hyperfibrinolysis has gases in the ventilator circuit may not prevent
been defined by a LY-30 equal to or greater than hypothermia, but it has been demonstrated to
3% on thromboelastography (TEG) [55, 56]. The slow the decrease in temperature [63]. Adjuvant
CRASH-2 trial incited interest in the preemptive measures include warming the ambient tempera-
administration of TXA to injured patients; how- ture of the operating room, warming the irrigation
ever the study methodology made it difficult to fluids, and wrapping the patient’s head. If the
apply broadly. At this time a rational approach patient becomes hypothermic despite the afore-
based on current data and expert opinion would mentioned preemptive measures to prevent hypo-
be to limit the use of TXA to trauma patients with thermia, then strategies like active intravascular
severe bleeding with fibrinolysis (i.e., TEG with rewarming have been shown to be successful
a LY-30 equal to or greater than 3%). TXA should [64]. Cardiopulmonary bypass has also been used
be administered within 3 h of the injury as it has successfully [65]. While lavage of the open abdo-
been shown that the use of TXA after 3 h of injury men and irrigation of chest tubes with warm fluid
resulted in increased mortality [57]. were commonly used in the past, they are rela-
tively ineffective in transferring heat and rarely
used in short-duration DCS. Once the patient
16.5 Hypothermia arrives in the ICU, the same measures are applied.
In our experience utilizing the above measures in
Hypothermia is an important component of the 95 DCS patients requiring a MTP hypothermia
“bloody vicious cycle” of death because it impairs was not a significant problem. At ICU admission,
coagulation, decreases cardiac output, and causes mean T was 35.4 ± 0.1 °C, 27 (28%) had a T
16  ICU Care Following Damage Control Surgery 175

between 32 and 35 °C, and only one (1%) had a T and it may worsen intracellular acidosis caused
<32 °C. Additionally, mean T increased rapidly to by carbon dioxide production. Bicarbonate infu-
>37 °C during the first 4 h of resuscitation and sion, therefore, is limited to persons in protracted
remained normal thereafter. severe shock. In our experience utilizing the
above measures in 95 DCS patients requiring a
MTP, severe acidosis was common at the start of
16.6 Acidosis ICU resuscitation, with 26 (27%) patients having
a pH between 7.0 and 7.2 but only three patients
Acidosis is an important component of the (2%) with a pH <7.0. With effective resuscitation
“bloody vicious cycle” of death because it and no sodium bicarbonate administration, the
impairs coagulation, decreases myocardial con- pH increased into the normal range within 8 h.
tractility, promotes cardiac dysrhythmias, and
inhibits oxidative metabolism and desensitized Conclusion
adrenergic receptors. Acidosis is a strong inde- Damage control surgery (DCS) has changed
pendent predictor of adverse outcomes including the surgical and ICU approach to critically ill
MOF, prolonged ICU stays, and death. Acidosis patients who arrive with severe bleeding.
is caused primarily by a rise in lactic acid produc- Following surgical interventions to prevent
tion secondary to tissue hypoxia and usually early death from exsanguination, the ICU
resolves when the volume deficit is corrected. goals are to reverse physiologic derangements
Administration of sodium bicarbonate may cause and prepare the patient for a second operation
a leftward shift in the oxyhemoglobin dissocia- where definitive operative treatment will be
tion curve, reducing tissue oxygen extraction, rendered (Table 16.1).

Table 16.1  Approach to intensive care following damage control surgery

Approach Goal(s)
Mechanical ventilation Provide adequate analgesia and sedation Assure patient-ventilator synchrony
Resuscitation end points Implement a resuscitation protocol Optimal end points have not been
identified. A resuscitation protocol will
assist in identifying nonresponders who
need alternative interventions
Crystalloid vs. colloid Initial resuscitation with crystalloid. Judicious use of crystalloid, knowing
Albumin used following administration that there are negative consequences of
of 6 l of crystalloid. Hydroxyethyl large-volume crystalloid resuscitation.
starches are not used in shock Safe use of colloid to limit crystalloid
resuscitation. volume
Blood transfusions Hgb is maintained >8 g/dL during active During active hemorrhagic shock
shock resuscitation with active bleeding. resuscitation, a higher Hgb provides a
Once bleeding is controlled, the Hgb is margin of safety, and blood will provide
maintained >7 g/dL volume and limit crystalloid
resuscitation. Otherwise, a restrictive
approach to blood transfusion has been
demonstrated to be safe and may be
beneficial
Correction of coagulopathy TEG goal-directed hemostatic therapy Significant reduction in unnecessary
blood component transfusion
Hypothermia Prevention of hypothermia Reversing hypothermia in the setting of
hemorrhagic shock is very difficult. The
goal is to prevent hypothermia from
occurring
Acidosis Focus on resuscitation Limit bicarbonate infusions to patients in
protracted severe shock and acidosis
176 C.W. Lee et al.

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hypothermia-­ induced platelet activation: possible Cochrane Database Syst Rev. 2015;(4):CD009891.
implications for cooling patients in cardiac surgery. 61. Alderson P, et al. Thermal insulation for preventing
Thromb Haemost. 2007;97:608–16. inadvertent perioperative hypothermia. Cochrane
47. Valeri CR, et al. Hypothermia-induced reversible
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platelet dysfunction. Ann Surg. 1987;205:175–81. 62. Lin EP, Smith K, Valley RD. Wet forced-air warming
48. Tsuei BJ, Kearney PA. Hypothermia in the trauma blankets are ineffective at maintaining normothermia.
patient. Injury. 2004;35:7–15. Paediatr Anaesth. 2008;18:642–4.
49. Mohr J, et al. Induced hypothermia does not impair 63. Jo YY, Kim HS, Chang YJ, Yun SY, Kwak HJ. The
coagulation system in a swine multiple trauma model. effect of warmed inspired gases on body temperature
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50. Ferrara A, MacArthur JD, Wright HK, Modlin IM, anesthesia. Korean J Anesthesiol. 2013;65:14–8.
McMillen MA. Hypothermia and acidosis worsen 64. Kiridume K, et al. Clinical experience with an active
coagulopathy in the patient requiring massive transfu- intravascular rewarming technique for near-severe
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Pragmatic Randomized Clinical Trial Comparing a 1997;337:1500–5.
Viscoelastic Assay to Conventional Coagulation
 Damage Control Phase III: Repair
of All Injuries, General Surgery
17
Babak Sarani and Patrick Maluso

17.1 G
 oals and Timing of Damage concern for a missed injury. Definitive repair
Control Phase III should be delayed but early operative re-­
exploration to evaluate for missed injury may be
The primary goals of the third phase of damage warranted. On-demand repeat laparotomy in
control surgery (DC III) are to achieve definitive these cases can decrease patient mortality [1].
repair of organ injuries and to close the fascia Some notable scenarios exist wherein earlier
over surgical wounds where possible. Although timing of definitive repair is potentially favor-
the optimal timing is variable and dependent on able. For example, in peripheral vascular injury,
numerous patient factors, DC III is typically thrombosis of a temporary shunt and subsequent
undertaken 24–36 h after the initial surgery. This potential for tissue loss may motivate earlier ini-
time is needed for appropriate resuscitation, tiation of DC III. There are no studies assessing
allowing the patient to reestablish proper homeo- the maximal time that bowel segments can be left
stasis. The patient will thereby tolerate the longer in discontinuity, but most trauma surgeons rec-
operative time and more extensive intervention(s) ommend creation of anastomoses or stoma to
that may be necessary to definitively repair the decompress isolated segments of the intestine no
injuries sustained. Specifically, the decision to later than 96 h following DC I. It is logical to
proceed with DC III should not be undertaken assume that earlier anastomosis or creation of a
until the patient’s coagulopathy has been cor- stoma is preferred, as long as the patient has been
rected and he/she is normothermic and has a nor- appropriately resuscitated and normal physio-
mal acid-base balance. Additional considerations logic milieu reestablished.
such as vasopressor requirements also impact on
the timing and probability of success of DC
III. Ideally, patients should be weaned off of 17.2 R
 epair of Injuries: General
vasopressors entirely or, at a minimum, their Considerations
pressor requirements should be decreasing.
Ongoing physiologic instability or hypothermia Once in the operating room, the patient should be
despite appropriate medical therapy should raise positioned, prepped, and draped to ensure ade-
quate exposure of all injuries to be addressed.
This may include extremity exposure sufficient to
B. Sarani, MD (*) • P. Maluso, MD allow proximal and distal control of vascular
Center for Trauma and Critical Care, Department of
Surgery, University of George Washington, DC, USA injuries and to allow for autologous vein harvest.
e-mail: bsarani@mfa.gwu.edu In cases where a single position to undertake all

© Springer International Publishing AG 2017 179

H.-C. Pape et al. (eds.), Damage Control Management in the Polytrauma Patient,
DOI 10.1007/978-3-319-52429-0_17
180 B. Sarani and P. Maluso

necessary repairs is not possible, phases of the strategy. In a review of surgical experiences sur-
operation should be planned preoperatively. The rounding the Korean and Vietnam conflicts, syn-
surgeon can also elect to stage the procedures thetic grafts were found to have a 77% complication
based on the patient’s physiologic reserve and rate and a higher incidence of amputation than vein
status. Communication and coordination with the grafts (31% vs 18%) [3]. The small numbers of
anesthesia team both before and during the oper- prosthetic grafts placed and high energy wounding
ation are vital in making these decisions, and the patterns limited this review. A study of 206 patients
surgeon must be prepared to adjust the operative with vascular trauma demonstrated that PTFE had
plan if the patient shows signs of instability. lower rates of long-term patency than autologous
grafts, but that infectious complications only
occurred in the setting of exposed graft and con-
17.3 Repair of Vascular Injury comitant osteomyelitis [4]. Similarly, a small study
using a canine model and a small number of trauma
Vascular repair in DC III involves removal of patients found that the use of vein conduits in con-
shunts placed in DC I and placement of interposi- taminated wounds was associated with a greater
tion grafts. Although vascular surgery can be con- incidence of vascular disruption than PTFE; how-
sulted to assist with definitive repair, excellent ever, the small numbers involved in the study limit
outcomes have been reported following vascular its generalizability [5]. In a subsequent retrospec-
repair by experienced trauma surgeons [2]. As with tive review, Mitchell and Thal concluded that fears
elective vascular operations, proximal and distal of anastomotic dehiscence following infection of
control is obtained using atraumatic clamps. Next, vein autograft were overstated and found vein to be
the vessel wall should be inspected for damage to a safe conduit in vascular trauma [6].
the intima or muscular layers and should be In the absence of definitive data comparing
debrided as necessary. The portion of the vessel synthetic with autologous grafts in trauma
that was used to tie and fix the shunt in place should patients, the choice of conduit should be informed
be resected. If the ends of the vessel are not long by careful consideration of patient factors, which
enough to support a tension-free end-to-end anas- include the caliber of the damaged vessel, loca-
tomosis, an interposition graft should be fashioned. tion (extremities versus trunk), and amount of
Prior to completion of the anastomosis, care should contamination present within the wound. Large
be taken to remove any intraluminal thrombus. The vessels can be treated with either prosthetic graft
proximal vessel is allowed to bleed for several or cadaveric homografts [7, 8]. While use of syn-
pulses, while the distal vessel may be allowed to thetic grafts allows for speedier operation and
backbleed in order to remove thrombus. A Fogarty obviates the need to create more wounds, use of
balloon catheter should be used to remove clot. The autologous material or homograft may be associ-
full technique for performing a vascular anastomo- ated with lower infection and therefore anasto-
sis is standardized, and full details are beyond the motic dehiscence rates. Regardless of the choice
scope of this chapter. Use of extraanatomic bypass of conduit, every attempt should be made to cover
may be necessary when autologous sources are the anastomosis in order to prevent complications
unavailable and contamination is severe. such as pseudoaneurysm formation or actual free
The choice of conduit is an important consider- disruption and life-threatening hemorrhage.
ation in planning repair of vascular injuries. The
choice between autologous conduit (commonly a
reversed saphenous vein graft) and synthetic alter- 17.4 R
 epair of Injuries: Solid
natives such as polytetrafluoroethylene (PTFE) Organ Abdominal Injuries
remains controversial. Data regarding where syn-
thetic grafts can be safely used following damage Following removal of the temporary abdominal
control surgery are conflicting, and there are no closure device, the abdominal contents should be
definitive, well-designed trials upon which to base carefully inspected with particular attention paid to
17  Damage Control Phase III: Repair of All Injuries, General Surgery 181

any repairs made during the index operation and to be safe and appropriate in DC III, creation of
for identification of possible missed injuries. an anastomosis involving the large intestine
Special consideration is required in patients fol- requires careful consideration. Overall, the litera-
lowing ballistic injuries as the zone of injury can ture favors primary repair and the creation of
extend beyond the direct path of the projectile, delayed anastomosis after damage control lapa-
resulting in a delayed manifestation of the true rotomy but with due consideration of known risk
extent of injured tissue. This may necessitate fur- factors for anastomotic leak. In one meta-­analysis
ther bowel resection to allow for safe anastomosis. of randomized controlled trials, primary repair
Similarly, the severity of pancreatic injury had lower morbidity and procedure-related cost
may be better assessed during this phase because than diversion with no difference in mortality
small volume leak from the pancreatic substance [13]. A similar multicenter prospective random-
will manifest as saponification. This finding will ized study of 297 patients found no difference in
frequently lead the trauma surgeon to drain the abdominal complications between the ostomy
pancreatic bed or consider pancreatic resection, and primary anastomosis groups, irrespective of
depending on the nature of the injury and timing associated risk factors [14]. A single-institution
since injury [9]. review of patients with colonic injury following
Severe hepatic injury is often initially man- penetrating trauma found that 81% were success-
aged with packing and embolization or ligation fully treated with delayed anastomosis of their
of bleeding vessels. At the time of DC III, injuries following damage control laparotomy
depending on the location and severity of the but found that persistent metabolic acidosis or
injury, resection of devitalized segments of the intraabdominal contamination were risk factors
liver may be necessary. Whereas most surgeons for leak [15]. Other smaller studies also support
avoid hepatic resection as much as possible, one this finding, demonstrating that delayed anasto-
study found that an aggressive debridement strat- mosis and immediate anastomosis have similar
egy resulted in a significant decrease in the over- complication rates [16]. Recent military data also
all number of procedures as well as complications. have shown no difference in complications
However, this approach was also associated with between delayed anastomosis and diversion [17];
a significant risk of intraoperative hemorrhage however, one study found lower complication
[10]. At the least, the presence of devitalized rates in patients treated with an immediate
hepatic tissue or deep laceration should raise ostomy than those who underwent damage con-
concern for a postoperative bile leak or abscess, trol [18]. Conversely, other studies have found
and the region should be drained preemptively. that delayed colonic anastomosis has higher
The right hemidiaphragm should be inspected in complication rates than seen with anastomoses
any injury pattern that includes significant hepatic created in a single laparotomy, suggesting that
injury. Diaphragmatic defects should be repaired as the open abdomen is particularly deleterious to
best as possible in order to decrease the risk of bil- the viability of colonic anastomoses [19–21].
iopleural fistula [11]. Although rare, formation of a Although there is no clear consensus, overall
biliopleural fistula is associated with the need for these studies suggest that delayed anastomosis is
prolonged tube thoracostomy and possible respira- a viable and safe management strategy for colonic
tory failure due to inflammation of the lung [12]. injury within the damage control sequence.
Following creation of an anastomosis, studies
suggest a significant risk of enteral leak if the
17.5 R
 epair of Gastrointestinal abdominal wall is not closed. While a perceived
Injury inability to definitively close the abdomen should
not rule out anastomosis during DC III opera-
The repair of gastrointestinal injuries during DC tions, the risk of leak and fistula formation with a
III is a complex issue. Although creation of a persistent open abdomen must be taken into con-
small bowel anastomosis is generally considered sideration. If the abdomen is left open following
182 B. Sarani and P. Maluso

definitive repair of bowel injury, conventional subsequent depression of blood pressure can be
teaching involves attempting to minimize these especially deleterious. Because of their inability
risks by covering anastomoses with omentum or to tolerate the possible septic complications of an
bowel. Studies supporting this intervention anastomotic leak, patients with TBI and risk fac-
involve esophageal anastomoses [22]; there are tors for leak should be managed with an ostomy
no studies upon which to base this strategy fol- rather than attempt at anastomosis during DC III
lowing damage control operation. operations. Similarly, elderly or chronically ill
Potential for abdominal closure is not the only patients with little physiologic reserve are less
important determinant of optimal surgical man- likely to survive the septic complications of an
agement of bowel injuries. The decision between anastomotic leak, and preference should be given
creation of an anastomosis during DC III and for- to formation of an ostomy in these cohorts.
mation of an ostomy should be undertaken after The anatomic location of the injured bowel is
consideration of the patient-specific risk factors. important in determining whether to attempt
Factors such as the presence of significant medi- anastomosis. Proximal small bowel injuries
cal comorbidities, tobacco use, and malnutrition should be managed during DC III with anasto-
present well-known risks for anastomotic leaks mosis whenever possible in order to maximize
[23–25]. Other risk factors that are especially rel- the amount of bowel available for absorption and
evant to trauma patients and to patients undergo- to reduce complications related to malnutrition
ing damage control laparotomy include ongoing and electrolyte shifts during recovery. Although
malperfusion due to sepsis, cardiopulmonary not specific to trauma, the colorectal surgical lit-
failure, or any other cause as well as periopera- erature demonstrates higher leak rates for low
tive blood transfusions [26]. Unfortunately, there colonic and rectal anastomoses, suggesting that
are few studies evaluating risk factors specifically these injuries should be treated with creation of
due to delayed anastomosis following injury. an ostomy or at least protected initially by a prox-
Demetriades et al. found that anastomotic leak imal diverting stoma [26]. Similarly, left-sided
was increased in penetrating trauma patients with anastomoses present a risk factor for anastomotic
severe fecal contamination, transfusion of four or leak [19].
more units of blood within the first 24 h, and in Creation of a stapled versus hand-sewn anas-
those who received single-agent antibiotic pro- tomosis during DC III remains controversial.
phylaxis perioperatively [27]. Another study of One multicenter retrospective study showed a
patients undergoing colon resection for cancer slight increase in leak rates for stapled anastomo-
found that the probability of leak was indepen- ses in trauma patients [30], and another study
dently associated with the American Society of showed a more than twofold increase in risk for
Anesthesiologists grade and need for emergency anastomotic leak in stapled anastomoses in emer-
operation [28]. Similarly, perioperative vasopres- gency general surgery patients [31]. The possible
sor requirements are associated with a more than reason to account for this involves bowel edema
fourfold increase in anastomotic leak rates [29]. which may preclude adequate sealing of the two
These findings underscore the importance of loops of the intestine using a stapler. However, a
appropriate timing of DC III operations. If patient prospective multicenter study of trauma patients
risks cannot be adequately managed in a timely showed no difference in outcomes between the
fashion, bowel anastomosis should not be under- two techniques [27]. Furthermore, while not spe-
taken at the time of DC III operations, and instead cific to trauma patients, one randomized
an ostomy should be formed with closure of the ­prospective study of 652 patients found no sig-
abdomen. Alternatively, the timing of DC III nificant difference in leak rates between stapled
should be delayed. and hand-sewn anastomoses [32], and a larger
Patients with traumatic brain injury rely on prospective study of 1,417 patients with anasto-
maintenance of normal cerebral perfusion pres- moses above the peritoneal reflection also found
sure, and in these patients any septic insult and no difference in leak rates [28]. Ultimately, the
17  Damage Control Phase III: Repair of All Injuries, General Surgery 183

surgeon’s technical proficiency with each tech- the incidence of complications and is inversely
nique should determine the operative approach to related to the probability of primary fascial clo-
anastomosis with the understanding that the sure [33]. If repeated attempts at fascial closure
operative strategy must be tailored to the patient are unsuccessful, the abdominal wall should be
and the condition of the tissues. closed using an inlay mesh or via intentional cre-
If creation of an anastomosis during DC III is ation of a ventral hernia with skin-only closure.
ruled out based on any of the above factors, stoma Planned future ventral herniorrhaphy may be
formation should be undertaken. When creating necessary with either technique.
an ostomy, the site should be chosen in order to Primary fascial closure is the optimal method
minimize potential for fecal contamination of the for closing the abdomen. This technique involves
midline laparotomy wound and subsequent the direct approximation of the fascial edges and
necrosis of the abdominal fascia. Choice of an has the lowest incidence of hernia and enterocu-
ostomy site 3–4 cm lateral to the lateral edge of taneous fistula formation following damage con-
the rectus abdominis muscle in order to reduce trol laparotomy. Although complications are less
proximity to the midline laparotomy wound may likely with primary fascial closure, care must be
help to minimize risks associated with spillage of taken to avoid excessive tension on the abdomi-
intestinal contents into the surgical wound and nal wall, as this can precipitate failure of the clo-
will facilitate application of stoma appliances sure or may predispose patients to development
without interfering with midline wound dress- of abdominal compartment syndrome [34].
ings. Furthermore, such lateral placement of sto- Although it is the preferred method for abdomi-
mas will facilitate component separation closure nal wall closure, a ventral hernia will develop in
of the abdominal wall should the patient develop up to 30% of these patients [35]. Although not
a hernia. studied well, primary fascial closure can be aug-
Lastly, consideration for placement of feeding mented with mesh reinforcement in an attempt to
tubes or tubes to decompress the alimentary tract lower this risk [36, 37]. Permanent, synthetic
is appropriate during this phase of damage con- meshes are relatively contraindicated in patients
trol operation. The overall care plan must now with risk factors for mesh infection such as
also include how to allow the patient to conva- wound soilage, and many authors recommend
lesce. Durable enteral feeding access should be use of biologic mesh in these instances. More
considered prior to abdominal closure as gastros- advanced techniques of fascial closure such as a
tomy or jejunostomy tube placement may be risk separation of abdominal wall components later-
prohibitive after DC III. When placed, the tubes ally to allow for direct apposition of the fascia at
should exit the abdominal wall well away from the midline may be used, but a detailed discus-
the lateral border of the rectus abdominis mus- sion of these methods is beyond the scope of this
cles so as to minimize risk that a leak will con- chapter [38, 39].
taminate the midline wound. In addition, as If primary fascial closure is not possible, an
discussed above, leaving the medial border of the alternative is functional closure by placing a
external oblique muscle unviolated facilitates a mesh inlay as a bridge between the edges of the
later component separation operation. fascia. Most commonly, a biologic mesh is used
due to concern about infection. The mesh acts as
a scaffolding for ingrowth of native fascial tissue
17.6 Abdominal Wall Closure [40]. Once the mesh is placed, the skin is closed
and drains can be placed to prevent seroma accu-
Once all necessary operative goals are met, defin- mulation as needed. Unfortunately, the natural
itive abdominal closure should be attempted as evolution of an inlay placement of biologic mesh
quickly as possible to minimize the deleterious is development of a “neo-hernia” due to stretch-
effects of an open abdomen. The length of time ing of the mesh over time. This can lead to patient
the abdomen is left open correlates directly with dissatisfaction and need for repeat operative
184 B. Sarani and P. Maluso

repair. While the late incidence of ventral hernia 4. Feliciano DV, Mattox KL, Graham JM, Bitondo
CG. Five-year experience with PTFE grafts in vascu-
formation after functional closure is not well
lar wounds. J Trauma. 1985;25:71–82.
established, one study using acellular dermal 5. Shah PM, Ito K, Clauss RH, Babu SC, Reynolds BM,
matrix found an 80% incidence over a mean fol- Stahl WM. Expanded microporous polytetrafluoro-
low-­up of 21.4 months despite skin closure over ethylene (PTFE) grafts in contaminated wounds:
experimental and clinical study. J Trauma.
the mesh [41].
1983;23:1030–3.
If skin closure is not possible, inlay placement 6. Mitchell 3rd FL, Thal ER. Results of venous interpo-
of biologic mesh should be avoided as exposed sition grafts in arterial injuries. J Trauma.
mesh will undergo degradation and dissolution 1990;30:336–9.
7. Chiesa R, Astore D, Piccolo G, Melissano G, Jannello
until it is replaced by granulation tissue over the
A, Frigerio D, Agrifoglio G, Bonalumi F, Corsi G,
viscera. Rather, a less expensive dissolving mesh, Costantini Brancadoro S, et al. Fresh and cryopre-
such as Vicryl™, can be used. This process usu- served arterial homografts in the treatment of pros-
ally occurs over 3–6 weeks. The resultant granu- thetic graft infections: experience of the Italian
Collaborative Vascular Homograft Group. Ann Vasc
lation tissue will require skin grafting and will
Surg. 1998;12:457–62.
ultimately lead to a ventral hernia which can be 8. Lavigne JP, Postal A, Kolh P, Limet R. Prosthetic vas-
repaired in 8–12 months when the inflammatory cular infection complicated or not by aortoenteric fis-
process in the abdomen has resolved and the vis- tula: comparison of treatment with and without
cryopreserved allograft (homograft). Eur J Vasc
cera are again mobile [42]. This delayed ventral
Endovasc Surg. 2003;25:416–23.
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requiring resection: a multicenter study. J Trauma. Miller RS. Acellular dermal allograft for ventral her-
2002;52:117–21. nia repair in the compromised surgical field. Am Surg.
28. Choi HK, Law WL, Ho JW. Leakage after resection 2006;72:1181–7. discussion 7–8
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 Phase III: Second Operation:
Repair of All Injuries, Orthopedic
18
Surgery

Hans-Christoph Pape and P. Giannoudis

18.1 Introduction syntheses of the femur, pelvis, and spinal column –

can represent an additional burden. Major surgeries
Definitive fixation of major fractures may occur have been described to be associated with systemic
within 24 h in stable patients or in borderline ones complications, such as SIRS and organ failure, if per-
that respond adequately to resuscitation, as men- formed at the wrong time, or in a patient that is not
tioned in Chap. 10. In those patients submitted to yet ready to tolerate the surgical impact. In a clinical
damage control procedures within the resuscita- study, a new onset of organ failure or deterioration of
tion period, such as external fixation or traction, existing SIRS occurred in almost half of patients
the second stage of fixation can be planned thor- undergoing major surgeries, while only 32% demon-
oughly according to the patient status. strated complications after minor surgeries [1].
In this light, it is well described that a patient’s Interestingly, the clinical deterioration did not
competence to endure a surgical procedure is entirely correlate with the duration of the surgery
determined by the interplay between the time or the degree of intraoperative hemorrhage. In
after injury, the magnitude of the operation, and contrast, some patients appeared to have present
the patient’s individual physiological response. It with a hyper inflammatory state prior to the pro-
is a prerequisite to respect local tissue and wound cedure, which was discussed to play a role in the
factors such as swelling, skin condition, or lesions development of their complications.
located close to the planned surgical incision. The principles described below have to be
Among the factors responsible for influencing the viewed with respect to the limitations of clinical
physiological response, cardiovascular, respiratory, studies: The separation of the effects of surgery
and immunologic factors are known to play a role. from other factors in polytrauma patients repre-
The magnitude of surgery – such as secondary osteo- sents a challenge. Well-defined patient popula-
tions are required, and inclusion of adequate
H.-C. Pape, MD, FACS (*) patient numbers appears to be difficult to achieve.
Professor and Chairman, Department of Trauma,
Zurich University, Raemistr. 100,
8091 Zurich, Switzerland 18.1.1 Effects of Surgery: Time
e-mail: papehc@aol.com and Magnitude
P. Giannoudis
Department of Orthopaedics, University of Leeds, Historically, the postsurgical response is well
Leeds, England
described: An inflammatory and hypermetabolic
e-mail: pgiannoudi@aol.com

© Springer International Publishing AG 2017 187

H.-C. Pape et al. (eds.), Damage Control Management in the Polytrauma Patient,
DOI 10.1007/978-3-319-52429-0_18
188 H.-C. Pape and P. Giannoudis

state occurs after every major surgery. Early ondary surgeries. A hyperinflammatory state is
descriptions by Billroth demonstrated delays in known to occur in every polytrauma patient.
wound healing and an increased risk of infection. Subsequently, depending on the general
Following these descriptions of the metabolic ­condition and the severity of the injury, a com-
answer, it became clear that more complex mech- pensatory phase (CARS) has been discussed. It
anisms occur [2, 3]. may be followed by a period of anergy. Whether
Similar mechanisms occur after surgical or or not the anergic phase develops and whether
accidental trauma: The nervous system activates there are any clinical consequences are difficult
the hypothalamus – pituitary axis, which or to foresee, and the determining factors are dis-
releases hormones such as cortisol, glucagon, cussed below. Recently, the “Inflammation and
catecholamines, and numerous inflammatory the Host Response to Injury Collaborative
cytokines [4]. Research Program” has gathered a large pro-
According to our current understanding, the spective data set on early patient assessment in
surgical stress response has three key compo- patients with blunt multiple trauma. The infor-
nents [5]: mation collected by this group clearly shows the
relevance of numerous clinical parameters and
1 . Sympathetic nervous system activation biomarkers for prediction of clinical complica-
2. Endocrine response with pituitary hormone tions, such as pulmonary dysfunction. Moreover,
secretion and insulin resistance the data underline the special meaning of the
3.
Immunologic and hematologic changes trauma-induced inflammatory response as an
including cytokine production, acute phase independent risk factor for adverse outcome.
reaction, neutrophil leukocytosis, and lym- The authors discuss that many changes are set at
phocyte proliferation the time of injury [6].

18.1.1.1 Sympathetic Nervous

System 18.1.2 Clinical Studies
The sympathoadrenal response directly modifies on the Relevance
the function of numerous organs, including the of Biochemical Markers
liver, pancreas, and kidney. Gluconeogenesis is
increased, glucagon production is stimulated, and Inflammatory markers appear to be relatively
water is retained to maintain fluid volume and stable indicators for the assessment of the clinical
cardiovascular homeostasis. course. Roumen’s classical publication compared
several inflammatory mediators and highlighted
18.1.1.2 Endocrine Response that Il-6 is most specific for trauma patients,
During the endocrine response, increased while TNF-α and Il 1-ß demonstrated a greater
catabolism mobilizes substrate to provide accuracy in patients with hemorrhage and in non-
energy and retention of salt and water to main- survivors after ARDS and MOF [7]. Our group
tain fluid volume and cardiovascular homeosta- demonstrated that early elevated Il-6 levels were
sis. Specifically, corticotrophin stimulates able to discriminate trauma patients who later
cortisol secretion from the adrenal cortex develop MOF [8]. In patients undergoing ortho-
resulting in increased blood glucose levels, pedic operations, interleukin-6 serum levels have
arginine vasopressin stimulates the kidney to been demonstrated to be closely related with the
retain water, and insulin secretion by the pan- magnitude of the injury (burden of trauma) and
creas is often diminished [5]. with the operative procedure (second hit) [9]. Il-6
concentrations vary according to the type of
18.1.1.3 Inflammation orthopedic surgery, as the inflammatory response
Inflammation appears to be the most important induced by femoral nailing is biochemically
parameter in terms of changes induced by sec- comparable to that induced by uncemented total
18  Phase III: Second Operation: Repair of All Injuries, Orthopedic Surgery 189

hip arthroplasty. In contrast with Il-6 and 8, the demonstrated an earlier window of PMNL prim-
clinical significance of other cytokines is ing. The in vitro oxygen radical release by
­controversial. While Smith et al. described an unstimulated PMNLs was resolved by 72 h. The
Il-10 increase after major surgery [10], Hensler authors concluded to “postpone avoidable second
depicted noticeably defect of its secretion [11]. hits” [15].
Therefore, Il-10 may not be an adequate param- Ogura et al. demonstrated a significant prim-
eter to monitor the severity of trauma. Likewise, ing of PMNLs in trauma patients between days
tumor necrosis factor alpha is unable to quantify 2 and 13. This reaction was most sustained at
the burden of blunt trauma or of surgical proce- days 2–5 after the injury and was thought to be
dures [12]. related to the length of the inflammatory
We previously looked at the timing of major response. The authors also investigated the
secondary surgery and investigated whether the effect of a second hit on inflammatory parame-
inflammatory response is different when early ters in trauma patients. Their measured IL-6
(days 2–4 after injury) or late (after day 4 fol- levels demonstrated a 2.5-­fold elevation after a
lowing injury) surgery is performed. In 128 second hit and a significant increase in the
polytraumatized patients, secondary surgery on FMLP response in PMNLs after a second hit
days 2–4 was associated with a higher inci- [16]. The manifold interactions between differ-
dence of postoperative organ dysfunction ent inflammatory cells and their secreted medi-
(46.5%) than secondary surgery on days 5–8. ators are well described. Johnson et al. reported
An association between the combination of ini- that IL-6 augments the cytotoxic potential of
tial Il-6 values > 500 pg/dl surgery on day 2–4 neutrophils via selective enhancement of elas-
and the development of MOF (r = 0.96, tase release [17].
p < 0.001) was also observed. In contrast, Recently, the importance of both, biochemical
no correlation between the initial Il-6-­values and clinical markers has been stressed. The EPOFF
> 500 pg/dl and surgery on days 5–8 (r = 0.57, study group looked at these issues and reconfirmed
p < 0.07) was discernable. Therefore, it was that multiple clinical parameters are important.
concluded that no distinct clinical advantage in Among these are lung function, coagulation,
carrying out early (day 2–4 days) secondary parameters of hemorrhage, and soft tissue injuries
definitive fracture fixation could be determined. [18]. Others have investigated clinical predictors
In contrast, in patients who demonstrated initial of complications and compared them with bio-
Il-6 values above 500 pg/dl, it was evident that chemical markers (Acute Physiology And Chronic
it may be advantageous to delay the interval Health Evaluation III [APACHE III], organ fail-
between primary temporary fracture stabiliza- ures, age, underlying cause, alveolar-­arterial oxy-
tion and secondary definitive fracture fixation gen gradient, plateau pressure) predicted mortality
for more than 4 days. The main conclusion was with an area under the ROC curve (AUC) of 0.82;
that in patients with blunt multiple injuries a combination of eight biomarkers and the clinical
undergoing primary temporary fixation of predictors had an AUC of 0.85.
major fractures, the timing of secondary defini- Their best biomarkers were the neutrophil
tive surgery should be carefully selected, chemotactic factor, IL-8, and SP-D, a product
because it may act as a second-hit phenomenon of alveolar type 2 cells. The authors focused
and cause a deterioration of the clinical status particularly on pulmonary complications. It is
[13]. This assumption is supported by numer- therefore not surprising that they suggest acute
ous studies: inflammation and alveolar epithelial injury as
Tanaka et al. reported that superoxide produc- important pathogenic pathways in human ALI/
tion by neutrophils (PMNLs) stimulated with ARDS [19]. Moreover, they conclude that a
concanavalin A and cytochrome d was elevated combination of biomarkers and clinical predic-
in trauma patients at day 3 after trauma and tors is superior to clinical predictors or bio-
returned to normal by day 7 [14]. Botha et al. markers alone for predicting mortality and may
190 H.-C. Pape and P. Giannoudis

be useful for stratifying patients in clinical ability for this purpose since its variability is too
trials. high to be able to judge the surgical risk on a
In summary, the numerous clinical and experi- daily basis. There are no investigations in terms
mental investigations regarding the inflammatory of the reliability of the clinical prognosis of an
response support the theory that the timing of experienced surgeon.
major secondary surgery does affect the clinical When the clinical course is uneventful, signs
course in patients with blunt trauma. of posttraumatic inflammation diminish usually
within 48-72 hours. In patients who have a high
risk for organ failure, the hyperinflammatory
18.1.3 Clinical Studies on the Effects state can last longer and is clinically determined
of Secondary Surgery by three major factors. If these factors are pres-
ent, patients are at high risk for secondary organ
The EPOFF study groups have gathered a lot of failure, and prolonged surgical interventions
information on the timing of primary and second- should be avoided (Tables 18.1 and 18.2).
ary surgeries. They combined the search for clini- Favorably, most patients do recover to a certain
cal and biochemical parameters [20, 21]. stage from their injuries and have a negative fluid
Some of their findings were based upon a ratio, normal chest x-rays, and normal cardiovas-
review of 4,314 polytrauma patients, where cular status. In these patients, we have made the
patients with blunt trauma and multiple surgeries clinical observation that the fourth postinjury day
were differentiated. Those patients that were sub- appears to be earliest at which a prolonged
mitted to major secondary surgery at days 2–4 ­non-lifesaving surgery can safely be performed.
after the initial injury demonstrated a higher inci- Other authors focused mainly on the aspect
dence of organ dysfunction than those o­ perated of pulmonary dysfunction. This might be rea-
between days 5 and 8 [22]. Similar observations sonable since ARDS used to be a major cause of
were made in a prospectively d­ ocumented cohort death before the syndrome of multiple organ
study [1]. The authors investigated a well-defined failure had been described. Certainly lung func-
cohort of 133 multiply injured patients that had a
well-selected high Injury Severity Score. In these Table 18.1  Time course of changes of biochemical
patients, the authors describe a deterioration of markers
the clinical status in as many as 38% of cases. Time after
One of the major common findings in these Author, year injury Comment/explanation
patient groups was that the deterioration of organ Tanaka 1991 Days 3–7 PMNL stimulation
elevated
function parameters began within a period of
Waydhas, 1996 First week Inflammatory parameters
48 h after surgery and after inflammatory param- react to surgery
eters had become abnormal. [23]. Botha, 1995 Day 3 PMNL unstimulated,
respond by hyperactivity
18.1.3.1 Clinical Parameters Ogura, 1999 Days 2–5 Priming PMNL
for Decision Making increased, elastase
release high
Classical indicators for the surgical risk such as
Giannoudis, First week Il-6, TNF,
old age, previous cardiac or chronic respiratory 1999 proinflammatory
illnesses are less important in the decision mak- response increased
ing for the operability for secondary surgery in Pape, 1999 First week Il-6, TNF, RES increased
polytrauma. Their prevalence is low within the Hensler, 1997 First week Il-10
usually young population of the polytraumatized. Pape, 2000 Days 2–4 Il-6 and Il-8
The classification of the “American Society of critical
Anesthesiologists” (ASA), is equally low in suit- Pape, 2007 Day 1 Hyperstimulation
18  Phase III: Second Operation: Repair of All Injuries, Orthopedic Surgery 191

Table 18.2 Criteria to allow for secondary surgical this, some authors have recommended that
fixation
fractures of the humerus shaft should be stabi-
PaO2/FiO2 ratio >250 lized by an intramedullary nail in polytrauma.
PEEP <8 cmH2O, each time for at least 24 h The ­ rationale to do so is that mobilization
preoperatively
with crutches is much more frequently
No additional infiltration in chest plain radiographs
obtained when s­ urgical fixation is performed.
Platelet count >95,000/μl
Usually, all other orthopedic fixation
Leukocyte count >2000/μl or <12,000/μl
Balanced or negative fluid ratio for 24 h minimum
­techniques remain the same, provided that all
before surgery soft tissue issues have been addressed (Table
Intra-cranial pressure <15 cmH2O, no signs of raised 18.3).
ICP in head CT Regarding the conversion of an external fixa-
Serum creatinine <2 mg/dl tion for the definite stabilization of major frac-
Serum bilirubin <3 mg/dl tures, infection is of time concern. Numerous
studies have shown that conversion should be per-
tion (often assessed via the pO2/FiO2 ratio) formed within a 14-day time interval, in order to
does play an important role. Patients with close minimize the infection-related complications.
to normal lung function (pO2/FiO2 quotient The hospital-acquired infections can be extraordi-
>280 mmHg) withstood a standard procedure in narily severe.
89% of the cases, while those with a worse Therefore, a conversion should be managed as
respiratory function developed a post-organ if a superficial infection is present. We have stud-
failure in 70%. ied this issue and developed a standardized proto-
A pO2/FiO2 ratio of <280 mmHg, a col for secondary conversion of an external
C-reactive protein of >11, and a platelet count fixator [24]. We have also demonstrated that
of <180,000/μl were accompanied with a clearly inclusion of this protocol leads to a reduction
increased incidence of a post-­operational organ of infectious complications in these patients
failure. As a further indicator, an increased level (Fig. 18.1).
of the preoperative inflammatory response was Briefly, the steps involve:
indicated, shown by an increased elastase con-
centration in the serum (>85 ng/ml). • Preoperative holding area/OR: thorough
cleaning with alcohol
• Removal of external fixation
18.2 Secondary Orthopedic • Prepping/draping
Stabilization: Technical • Excision of pin sites by one surgeon/over-­
Aspects drilling of pin holes
• Thorough irrigation
One of the major questions that orthopedic sur- • Change of gloves, equipment used for exci-
geons have to address after polytrauma is sion (drapes included)
whether the techniques of fracture fixation • Definitive procedure
should be the same as for isolated fractures.
Fortunately these aspects appear to be similar Conclusion
regardless the severity of injury, provided that The pathophysiological sequences after
the soft tissue aspects and the general patient’s accidental trauma show a biphasic pro-
condition are respected. cess of the immunomodulatory response.
Some considerations however may be The main peak of the inflammatory
­different. These are related to the principles response usually occurs during the first
of early patient’s mobilization. To achieve 24–48 h (Fig. 18.2). Within the following
192 H.-C. Pape and P. Giannoudis

Table 18.3  Fixation principles for orthopedic injuries in polytrauma patients

Similar to Different to
isolated isolated
trauma trauma
Anatomic area Technical aspects condition condition
Proximal humerus Plate osteosynthesis avoid hemiarthroplasty +
Humerus shaft Intramedullary nail +
Distal humerus Locked plate (as in isolated fractures) +
Elbow Cautious timing, beware of formation of heterotopic ossifications +
Forearm May be delayed +
Wrist/hand May be delayed +
Proximal femur May be delayed, avoid THA or hemiarthroplasty (patients usually young) +
Femur shaft As early as patient condition permits, consider undreamed, plating, or +
ex fix
Distal femur Delayed, technically comparable with isolated trauma +
Proximal tibia/ Delayed, technically comparable with isolated trauma +
tibial plateau
Tibia shaft Early, technically comparable with isolated trauma +
Distal tibia Delayed, technically comparable with isolated trauma +
Ankle/foot Delayed, technically comparable +
Pelvis Pelvic binder/C-clamp, consider least amount of blood loss +
Acetabulum Delayed, high infectious risk in ICU patients +
C-spine Early if neurodeficit +
Thoracic spine Delayed unless neurodeficit +
Lumbar Spine Early, if neurodeficit +
Sacrum Delayed, high infection risk for ICU patients +

• fixator in situ
• sterile gloves and sterile draping
• complete surface disinfection (e.g. Braunol*)
including fixator
STEP I • removal of fixator

• local excision of skin-pin interfaces

• currettage of soft tissue around pin track sites
• local disinfection and coverage of wounds and
pin tract sites (Figures 4 and 5)
STEP II

• leave the former pin sites covered

• DO NOT surgically close former pin sites but
cover with antibacterial dressing
• apply a cast
• wait 3-7 days until soft tissue recovage prior to
STEP III conversion

Fig. 18.1  Staged conversion of

external fixator
18  Phase III: Second Operation: Repair of All Injuries, Orthopedic Surgery 193

Fig. 18.2  Acute conversion of external

fixator
• external fixation in situ
• sterile gloves and sterile draping
• complete surface disinfection including fixateur
• removal of external fixation
STEP I

• local excision of skin-pain interfaces

• currettage of soft tissue around pin track sites
• local disinfection and coverage of wounds and
pin tract sites (Figures 4 and 5)
STEP II

• prepare for internal fixation

• renew sterile gloves and sterile draping
• perform disinfection and surgical coverage in
accordance to the planned operative technique
WHILE LEAVING the former pin sites covered
• perform internal fixation as planned
• close all wounds before uncovering the former
STEP III pin sites
• DO NOT surgically close former pin sites but
cover with antibacterial dressing (e.g. Braunol*)

week, s­ urgical trauma through a secondary 2. Thorell A, Nygren J, Ljungqvist O. Insulin resistance:

operation is shown to represent an addi- a marker of surgical stress. Curr Opin Clin Nutr Metab
Care. 1999;2(1):69–78. [PubMed]
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pulmonary function, normalization of Lancet. 1942;1:433–7.
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 Phase IV: Late Reconstruction,
Plastic Surgery for Orthopedics
19
LCDR Scott M. Tintle and L. Scott Levin

19.1 Orthoplastics functioning limb. When this team functions prop-

erly, a synergistic effect occurs, and all parties,
In 1919, Sir Harold Gillies wrote a pioneering most importantly, the patient, benefit.
textbook that has proven pivotal in the modern
development of plastic surgery. The preface to his
text was written by Sir W. Arbuthnot Lane, an 19.2 B
 rief History of Microsurgery
orthopedic surgeon, thus beginning the publicized in Orthopedics
modern era of “orthoplastic surgery” [27].
Orthoplastic surgery is not just a term that should The collaboration of orthopedic and plastic surgery
be casually used anytime a plastic and orthopedic can be largely summarized by the history of micro-
surgeon work on the same patient for it does not surgery. The concept of triangulation of a blood
define the true collaboration between orthopedic vessel was introduced by Alexis Carrel in 1902
and plastic surgeons who are capable of seeing which allowed for successful end-to-end vascular
that bone, muscle, tendon, and skin are best treated anastomosis. The fields of vascular surgery, plastic
compositely. One team does not fix the bone and surgery, and microsurgery were certain to develop
the other “cover” it. Orthoplastic surgery incorpo- following this profound discovery, for which Carrel
rates early involvement of both orthopedics and would be awarded the Nobel Prize in Physiology or
plastic surgery with plans developed and followed Medicine [39, 40]. With the development of the
by the team for the ideal treatment of the limb. operating microscope and instruments and suture
Timing of fracture fixation and soft tissue cover- small enough in caliber to suture the 1 mm blood
age are optimized for the betterment of the com- vessel, a revolution in every surgical discipline
posite limb and not for the schedule of the including orthopedic surgery followed.
individual teams. When the focus is diverted erro- The first thumb replantation was performed in
neously to one tissue, frequently the result can be Japan by Tamai in 1965, following the first arm
a perfused, possibly united, and covered but poorly replantation by Malt and McKhann in Boston in
1962 [40]. The 1960s ushered the era of Harry
Buncke and his numerous microvascular experi-
L.S.M. Tintle, MD, MC USN (*) ments and multiple advances to the field of
Walter Reed National Military Medical Center,
microsurgery which would eventually lead to the
Bethesda, MD 20889, USA
e-mail: scott.tintle@gmail.com title of the “father of microsurgery.” At this time,
digital and limb replantation were largely the
L.S. Levin, MD
University of Pennsylvania, impetus driving the research and surgical efforts
Philadelphia, PA 19104, USA in the development of microsurgery. The concept
© Springer International Publishing AG 2017 195
H.-C. Pape et al. (eds.), Damage Control Management in the Polytrauma Patient,
DOI 10.1007/978-3-319-52429-0_19
196 L.S.M. Tintle and L.S. Levin

of tissue coverage and pedicled flaps in which 19.4 Reconstructive Algorithm

large masses of tissue were transferred on an Principles
axial artery and vein pedicle was introduced by
McGregor in 1972 when he described the groin While initial treatment considerations have
flap. Shortly thereafter, the free tissue transfer largely been discussed in previous chapters, it is
was reported by Taylor and Daniel, and the era of imperative to highlight three paramount princi-
free tissue transfer was born [44]. ples that we feel are important to long-term suc-
The past 30 years has seen the evolution of cess in the treatment of these combined
microsurgery from the simple concept of replan- orthoplastic injuries:
tation to chimeric flaps, functional muscle trans-
fers, perforator, and even freestyle flaps. The 1. Appropriate antibiotics are always started and
advancements in microsurgery and the collabora- continued until all wounds are closed or it is
tion of orthoplastics have allowed for the concept deemed appropriate to stop by the combined
of limb replantation and the fields of solid organ team.
transplantation to come together in the field of 2. Aggressive wound debridement is performed
vascularized composite allotransplantation in the in the operating room every 48–72 hours until
hopes of complete restoration of function follow- definitive wound closure is achieved. Early
ing major extremity amputations. wound closure or flap reconstruction is gener-
ally performed as soon as is feasible.
3. In most cases, definitive wound coverage is
19.3 Orthopedic Trauma Surgery performed at the time or immediately follow-
ing the definitive internal fixation of fractures.
Trauma remains the most common reason for the Indications for internal fixation remotely prior
necessity of plastic surgery involvement in ortho- to definitive wound coverage are rare. Flap
pedics. The orthoplastic approach is imperative coverage with external fixation and a delayed
for routinely successful outcomes in complex definitive fixation is also a strong consider-
open fractures. The end-state goal is to obtain a ation in select cases.
non-infected union, healed soft tissues, and opti-
mal functional outcomes. For any plastic surgeon While presentation of all options for soft tis-
working closely with orthopedic surgeons, it is sue coverage of the extremities is outside the
imperative to understand the four basic surgical scope of this chapter, the following briefly
principles that the Arbeitsgemeinschaft fur describes our treatment considerations and
Osteosynthesefragen (AO) group developed for unique aspects of upper and lower extremity
the surgical treatment of fractures back in 1950. reconstruction.
These principles remain paramount:

1 . Anatomic reduction of fractures 19.5 Ladder of Reconstruction

2. Stable internal fixation
3. Preservation of blood supply with careful
The classic soft tissue ladder of reconstruction
attention to soft tissue handling recommends using the simplest, least morbid
4. Functional rehabilitation of the injured limb technique to achieve soft tissue coverage. In our
experience treating over a decade of war trauma
It is not coincidental that two of the four prin- and our combined many decades treating trauma
ciples, namely, the preservation of the blood at level 1 trauma centers, we have observed a
­supply and the rehabilitation of the injured limb, shift toward using free flaps for a number of rea-
involve the soft tissues. These principles high- sons when pedicled flaps may have been previ-
light the importance of preserving soft tissues in ously recommended [24, 47, 49]. The potential
order to achieve fracture union and optimal benefits of free tissue transfer are well described,
­outcomes [44]. and the soft tissue elevator has rapidly become
19  Phase IV: Late Reconstruction, Plastic Surgery for Orthopedics 197

the more utilized concept for soft tissue recon- e­ xtensively in the treatment of burns, and more
struction [7, 49]. This elevator concept is a sim- recently papers chronicling our war trauma
ple change in thought process and suggests that experience have begun to highlight the success
the optimal method of coverage for the best func- of these regenerative matrices [12, 37]. The use
tional outcome be utilized immediately even of a dermal substitute has multiple benefits in
when bypassing more simple measures which the treatment of large wounds, including: cover-
may achieve closure. The elevator considers age of exposed tendons, nerves, blood vessels,
more carefully the continued reconstruction nec- and/or bone. The use of this matrix may make a
essary, the end-state and rehabilitative goals. wound smaller and may altogether eliminate the
Clearly, more skill is needed as one rises up the need for a tissue transfer. Additionally, the use
reconstructive elevator, and this needs to be con- of the substitute helps develop a well-vascular-
sidered in the treatment planning. A unique con- ized bed. We have utilized the matrix to lessen
sideration in the elevator concept is the use of the need for shortening of amputated extremi-
biologic advancements that may simplify wound ties by providing more stable soft tissue cover-
coverage techniques. These biologics can be used age and durability [12, 17, 37]. The decision to
exclusively or more commonly as a combined utilize a dermal substitute in place of a tissue
approach to wound management along with other transfer is based on many factors. Clearly, the
more traditional techniques [4]. patient’s disease state, comorbidities, available
We have found the use of bioartificial dermal flap donor sites, other extremity injuries, and,
regeneration templates to be very useful in the realistically, cost all go into this decision. While
reconstructive efforts for patients with large the use of a dermal substitute beneath a split-
wounds. These dermal matrices have an impor- thickness skin graft does improve the ability to
tant role in the management of large, complex raise a viable skin flap upon reoperation for sec-
soft tissue injuries. These dermal regeneration ondary procedures (i.e., bone grafting, tendon
templates provide initial wound coverage and reconstruction, nerve grafting), we frequently
help establish a well-vascularized wound bed would proceed up the reconstructive elevator to
suitable for definitive soft tissue coverage. a free tissue transfer when we anticipate these
These dermal substitutes have been used procedures (Figs. 19.1a, b and 19.2a–c).

a b

Fig. 19.1 (a, b)
Osteocutaneous free fibula
performed for large
segmental defects of the
radius and ulna. Muscle
coverage achieved
temporarily with integra
dermal matrix followed by
excision and closure of
wound at 2 weeks from the
original flap procedure
198 L.S.M. Tintle and L.S. Levin

a b

Fig. 19.2 (a) Open small and ring finger fractures with after 3 weeks of integra placement. (c) Five days follow-
small finger extensor tendon repair covered with integra ing full thickness skin graft
(picture pre-integra placement). (b) Granulation tissue

19.6 T
 iming of Soft Tissue the flap was delayed, the longer the patients
Coverage spent in the hospital and the higher the infection
rates.
In 1986, Godina posthumously published his While the need for early radical debridement
landmark paper on the soft tissue coverage of and soft tissue coverage with vascularized tis-
532 patients with open wounds. This manuscript sue is well established in civilian literature [1, 5,
advanced microsurgery substantially and estab- 6, 9, 10, 13, 23, 51, 53], the days of Marco
lished the important soft tissue principles of Godina’s team in Ljubljana are different from
early aggressive wound debridement, early free what exists in most healthcare systems today.
tissue transfer, and aggressive rehabilitation in The tireless team of dedicated microsurgeons
order to optimize the functional outcomes [6]. who worked around the clock to provide early
While the concept of the emergency free flap definitive e­mergency soft tissue coverage of
was introduced, upon closer look at the work, open wounds is a rarity in today’s healthcare
the manuscript demonstrated no difference in environment.
the infection rates between the flaps that were While all efforts should be made in modern
performed at the first operative setting (emer- practice to get wounds covered rapidly, the mili-
gency free flaps) versus those that were per- tary experience and that of other civilian provid-
formed within the first 3 days of the injury. The ers has demonstrated acceptable outcomes with
paper did, however, demonstrate that the longer wound coverage in the subacute time period [15,
19  Phase IV: Late Reconstruction, Plastic Surgery for Orthopedics 199

24–26, 50]. While the variables that lead to suc- 19.7.1 Unique Lower Extremity
cessful soft tissue coverage in the subacute time Considerations
period remain ill defined, adherence to the estab-
lished principles of radical debridement to create In the lower extremity the reconstructive efforts
a clean wound bed and the use of healthy vascu- are imperative in order to return patients to even
larized tissue have led to successful wound cov- primitive weight bearing and ambulation.
erage with low flap failure rates and low rates of Coverage of open tibia fractures is the prototypi-
infection [47]. cal case in which a plastic surgeon is involved in
The literature is clear that successful results the care of an orthopedic fracture patient. This
can be obtained in the subacute time period, but case specifically highlights the importance of a
significant shortcomings in the reporting of well-thought-out orthoplastic treatment algo-
open fracture data are apparent highlighting the rithm. A recent review of IIIB tibia fractures at a
inconsistencies of treatment algorithms. While level 1 trauma center revealed an overall infec-
most authors of these soft tissue coverage tion rate of 36% when flap coverage was pro-
papers endorse a multidisciplinary approach vided in the first 7 days. When coverage was
(orthoplastic) to the management of these inju- provided later than 7 days after injury, the infec-
ries, the data is often published in a specialty tion rate soared to 57%. The treatment protocol
journal (orthopedics or plastic surgery) without included the use of a wound vacuum device
adequately addressing the composite nature of application following initial debridement and
the limb salvage protocol. It is not uncommon fracture stabilization frequently with an intra-
that the timing of and the type of initial and medullary nail, and then repeat debridement and
definitive fracture stabilization are not apparent irrigation every 48 h until definitive soft tissue
from the data presented. This unfortunately coverage. What is not clear from this study, how-
makes it very difficult to comprehend the impli- ever, is the timing or method of definitive fracture
cations of the overall limb salvage protocols fixation. The high rates of infection, even in the
presented. group that underwent flap coverage within
7 days, raise concern about the treatment proto-
col, and the long delay to flap treatment suggests
19.7 Flap Reconstruction poor orthopedic and plastic surgery collabora-
tion. In our experience, successful salvage of
In our experience, two types of flaps are most lower extremities with severe open tibia fractures
useful in extremity reconstruction: fasciocutane- is possible only with close orthoplastic relation-
ous and muscle. The debate over the optimal flap ships [21]. All fracture stabilization and soft tis-
for open fractures is common and will not be eas- sue procedures should be thoroughly coordinated
ily answered. Many studies have shown the util- by both the orthopedic and plastic surgeon with
ity of muscle flaps in bone healing, but the best overall outcome in mind—as opposed to
fasciocutaneous/perforator flaps have also the usual focus on either fracture union or flap
reported high success rates, and both appear to be viability.
viable options for extremity coverage [2, 11, 32– The foot and ankle have a highly specialized
35, 47, 48, 52, 53]. Fasciocutaneous flaps are uti- bony architecture and tissue properties that make
lized preferentially over muscle flaps in our coverage very challenging. It is important to con-
practice frequently because they spare core sider the various regions of tissue coverage in the
strength which is essential to functional recovery foot and ankle, and we frequently divide the tis-
of severely injured patients. Additionally the rel- sues into dorsum, posterior, and plantar cover-
ative ease of flap elevation for secondary proce- age. All have distinct properties and pose
dures such as bone grafting, tenolysis and/or challenges for differing reasons. The dorsum of
tendon repairs, and delayed nerve grafting com- the foot is very thin and frequently requires free
pared to muscle flaps is strongly desirable. tissue transfer for coverage. This region requires
200 L.S.M. Tintle and L.S. Levin

thin pliable tissue to cover the exposed bones, procedure as highlighted by Duhamel et al. [3]
joints, and tendons that are devoid of paratenon. (Fig. 19.3a–d). One of the most specialized skin/
Fasciocutaneous flaps are frequently utilized for adipofascial layers in the body is the plantar heel
this coverage as this allows the replacement of pad and the reconstruction of this region is very
thin, esthetic, “like with like” tissue that will difficult. While various fasciocutaneous, muscle,
hopefully allow for optimal shoe wear. The pos- and myocutaneous flaps have been described and
terior aspect of the foot and ankle is considered a utilized for this coverage, we have found it criti-
unique region because of the Achilles tendon and cal to have a muscle component of a flap for heel
its important role to ambulation. It is common coverage. We consider the following all viable
that the tendon has been compromised either by options for coverage of the heel: latissimus myo-
infection or trauma. This region is also a common cutaneous flap, rectus abdominis, vastus lateralis,
region for wound dehiscence [22]. In situations or an anterolateral thigh flap with vastus lateralis
where small flaps are necessary, the reverse sural muscle. It is imperative with any heel reconstruc-
is a viable option, but for larger flaps or in situa- tion that a patient critically protect the recon-
tions where the Achilles tendon has been com- struction. This is best accomplished through
promised, we have utilized the anterolateral thigh education and the proper selection or modifica-
flap and reconstructed the Achilles in a ­one-stage tion of a patient’s shoe [46].

a b

c d

Fig. 19.3 (a) Achilles tendon wound dehiscence and for Achilles reconstruction. (d) At final inset, note the ten-
infection with debridement of Achilles tendon. (b) Status sor fascia lata is rolled up and sutured into the calcaneous
post debridement with loss of Achilles tendon. (c) Design with suture anchors
of an anterolateral thigh flap with tensor fascia lata tissue
19  Phase IV: Late Reconstruction, Plastic Surgery for Orthopedics 201

19.7.2 Unique Upper Extremity

a
Considerations

The plastic surgeon or an orthoplastic approach to

the upper extremity is critical to the complete care
of upper extremity pathology. Hand surgery is a
subspecialty of both plastic and orthopedic surgery
and was originally conceived by Sterling Bunnell
to be a specialty capable of total composite care of
the upper extremity in a true orthoplastic fashion.
Unfortunately, despite the fact that microsurgery is
critical to the total care of the upper extremity, sub-
specialization within the field of hand surgery has b
diluted the training of hand surgeons, and micro-
surgical skill is declining among hand surgeons
[29]. For this reason, the plastic surgeon is fre-
quently vital to the combined orthoplastic recon-
struction of upper extremity defects.
While in the lower extremity the difficulty in
reconstruction is frequently the need to wear a shoe
and to bear weight, the upper extremity is compli-
cated by the necessary motion in order to be an
effective extremity. Motion is often compromised
by the underlying musculoskeletal trauma or con-
dition. This is very common at the elbow and the c
hand and these factors need to be considered in the
reconstructive effort. When deciding upon the
definitive soft tissue reconstruction, the need for
further tendon, nerve, or bone grafting needs to be
considered. Sometimes a skin graft will achieve
coverage, but it will make further reconstructive
efforts very challenging and a free tissue transfer
should be considered (Fig. 19.4a–c).

Fig. 19.4 (a) Large forearm fasciocutaneous loss with

median nerve deficit requiring grafting. (b) Forearm
19.7.3 Vascularized Bone Grafting
reconstruction with anterolateral thigh flap to facilitate
ease of flap elevation for definitive nerve grafting. (c)
Segmental bone loss and the eventual need for Similar forearm wound with no further reconstruction
bone grafting are common in severely injured necessary treated with integra followed by split thickness
skin grafting
patients. It is important for an orthoplastic team
to have an armamentarium of options with regard
to the creation of bone. Large segmental bone treatment of bone gaps. The use of microsurgery
gaps are challenging to reconstruct. Multiple has proven revolutionary in the creation of bone.
options to include conventional nonvascularized Ian Taylor described the vascularized fibula in
grafting, bone transport, and Masquelet 1975, and it has been widely utilized since due to
­techniques are all available and have a role in the its size, acceptable donor morbidity, and direct
202 L.S.M. Tintle and L.S. Levin

a b c d

Fig. 19.5 (a) Both bone forearm fracture nonunion sta- combined segmental ulna defect and soft tissue defect.
tus post internal fixation and multiple infections. (b) The radius was treated with a portion of the fibula in a
Infected nonunion with external fixation and antibiotic nonvascularized fashion. (d) Healed both bone forearm
spacers in place. (c) Osteocutaneous free fibula for the fracture

dissection [41–43]. These grafts have been

utilized extensively in the upper and lower
­
extremities for segmental defects as well as for
osteonecrosis of the hip. The flap is versatile as it
can be taken as bone only or as an osteomyocuta-
neous flap if desired due to its consistent peroneal
artery perforators (Fig. 19.5a–d).

19.7.4 Medial Femoral Condyle

While the fibula has historically been the most fre- Fig. 19.6  Medial femoral condyle vascularized bone
quently transferred vascularized bone, the medial graft with skin island
femoral condyle continues to grow in popularity
and is a necessary flap for smaller segmental bone descending genicular artery arose from the
defects in the extremities. Its use continues to grow superficial femoral artery just proximal to the
for carpal bones and long bone nonunions [18–20, adductor hiatus and then divided into two to
31]. It is additionally very useful to stimulate the three branches: the osteoarticular branch, the
union of a failed joint fusion [8]. The use of the muscular branch, and the saphenous branch.
medial femoral condyle has even been suggested The descending genicular artery was present in
for the use in intermediate to large osseous defects 89% of their specimens. It branched off of the
[16, 28]. Additionally, the graft can be taken with superficial femoral artery approximately
cartilage from the knee to provide an osteoarticular 13.7 cm above the knee joint. The superomedial
graft for reconstruction of joint surfaces [14]. genicular artery was present 100% of the time
Yamamoto et al. recently described the vascu- and is the alternative supplying vessel in cases
lar anatomy of the graft [16]. The team found where a patient does not have a descending
that the nutrient vessels of the medial femoral genicular artery. This dissection, however, is
condyle were consistently ­ supplied by the more challenging, and the average pedicle is
descending genicular artery, the superomedial only 5.2 cm in length and is on average 0.78 mm
genicular artery, or both. They found that the in diameter [16] (Fig. 19.6).
19  Phase IV: Late Reconstruction, Plastic Surgery for Orthopedics 203

a b

Fig. 19.7 (a) Open distal tibia fracture with original Patient was weight bearing as tolerated. (b) Flap follow-
plate fixation complicated by wound breakdown and hard- ing frame removal bone grafting and delayed open reduc-
ware removal. Treated with anterolateral thigh flap and tion and internal fixation
ringed external fixator. Note the ability to wear shoe.

19.8 Postoperative Care

The postoperative care of orthoplastic patients

is critical to the overall outcome. After a flap
reconstruction, we use splints and are liberal
with the use of an external fixator to ensure
that there is no pressure on a flap and to ensure
no tension on the vascular anastomosis or ped-
icle. The flap is left visible and a petroleum
gauze bandage is utilized to cover the suture Fig. 19.8  External fixation in place for tibia fracture and
lines. Internal Doppler devices are commonly anterolateral thigh flap. This external fixator was modified
utilized and/or surface monitoring if available. to prevent any pressure from being placed on the flap. This
external fixator was converted to a ringed external fixator
A surface perforator is often identified in order 3 weeks following the flap procedure
to do handheld Doppler checks postopera-
tively. Should any signs of venous congestion
or flap compromise be noted, then we return to weight bearing within 2 weeks and ambulation
the operating room urgently. Standard deep within 6 weeks of reconstruction when treating
vein thrombosis prophylaxis is utilized and lower extremity fractures [46] (Figs. 19.7a–b
patients are placed on a full-dose aspirin for and 19.8).
1 month. We believe in utilizing a staged dan-
gle approach that progresses to full freedom at
6 weeks. Inpatient consultations for occupa- 19.9 Vascularized Composite
tional therapy, physical therapy, rehabilitation Allotransplantation
medicine, and prosthetics are obtained the sec-
ond day of admission. After wound reconstruc- The pinnacle of the reconstructive ladder/elevator
tion, patients undergo extremity rehabilitation leads to vascularized composite allotransplanta-
limited only by the particular flap utilized. tion. This is the culmination of true restoration.
Range of motion is started as soon as feasible VCA has been fully realized and numerous hand
and early ambulation when the flap is ready is transplants have taken place to date [36, 45]. The
usually the goal. The use of state-of-the-art main current barriers to more widespread utiliza-
multiplanar spatial frames frequently f­ acilitates tion remain the refinement of immunosuppression
204 L.S.M. Tintle and L.S. Levin

with a move toward immunomodulation [30, 38]. 9. Hallock GG. Lower extremity muscle perforator flaps
The long-term outcomes or routine hand trans- for lower extremity reconstruction. Plast Reconstr
Surg. 2004;114(5):1123–30.
plantation still needs to be further researched. 10. Hallock GG. Utility of both muscle and fascia flaps in
Additionally, the early successes and failures with severe lower extremity trauma. J Trauma: Inj Infect
VCA highlight the psychological influence on the Crit Care. 2000;48(5):913–7.
outcomes that need to be further elucidated. 11. Harry LE, et al. Comparison of the vascularity of fascio-
cutaneous tissue and muscle for coverage of open tibial
Hopefully, in the near future, a refinement in the fractures. Plast Reconstr Surg. 2009;124(4):1211–9.
indications, the ethics, and ultimately the finances 12. Helgeson MD, et al. Bioartificial dermal substitute: a
of VCA will occur in order to sustain its contin- preliminary report on its use for the management of
ued growth. complex combat-related soft tissue wounds. J Orthop
Trauma. 2007;21(6):394–9.
13. Hertel R, et al. On the timing of soft-tissue reconstruc-
Conclusions tion for open fractures of the lower leg. Arch Orthop
For more than 50 years, advances have been Trauma Surg. 1999;119(1–2):7–12.
14. Higgins JP. Recalcitrant proximal pole nonunions
made in extremity salvage and reconstruction
reconstructed with medial femoral condyle osteoarticu-
using the operating microscope. Since 1991, lar graft. In: Scaphoid fractures and nonunions. Cham:
the orthoplastic approach has served as the Springer International Publishing; 2015. p. 225–35.
ideal approach to the traumatized limb, apply- 15. Higgins TF, Klatt JB, Beals TC. Lower extremity
assessment project (LEAP) – the best available evi-
ing principles and practices of both specialties
dence on limb-threatening lower extremity trauma.
to clinical problems simultaneously. The Orthop Clin N Am. 2010;41(2):233–9.
results of this approach optimize patient 16. Iorio ML, Masden DL, Higgins JP. The limits of

recovery, decrease costs, and improve func- medial femoral condyle corticoperiosteal flaps.
J Hand Surg. 2011;36(10):1592–6.
tional outcomes.
17. Jeng JC, et al. Seven years’ experience with Integra as a
reconstructive tool. J Burn Care Res. 2007;28(1):120–6.
18. Jones DB, Shin AY. Medial femoral condyle vascular-
ized bone grafts for scaphoid nonunions. Chir Main.
2010;29(Suppl 1):S93–103.
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skin or perforator flaps for extremity salvage. Plast ment of traumatic osteocutaneous defects of the lower
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36. Salminger S, et al. Hand transplantation versus hand 51. Yazar S, et al. Outcome comparison between free
prosthetics: pros and cons. Curr Surg Rep. 2016;4(2): muscle and free fasciocutaneous flaps for reconstruc-
1–7. tion of distal third and ankle traumatic open tibial
37. Seavey JG, et al. Use of a bioartificial dermal regen- fractures. Plast Reconstr Surg. 2006;117(7):2468–75.
eration template for skin restoration in combat casu- 52. Yazar S, Lin C-H, Wei F-C. One-stage reconstruction
alty injuries. Regen Med. 2016;11(1):81–90. of composite bone and soft-tissue defects in traumatic
38. Swearingen B, et al. Science of composite tissue allo- lower extremities. Plast Reconstr Surg. 2004:1457–66.
transplantation. Transplantation. 2008;86(5):627–35. 53. Yildirim S, Gideroğlu K, Aköz T. Anterolateral thigh
39. Tamai S. History of microsurgery – from the begin- flap: ideal free flap choice for lower extremity soft-­
ning until the end of the 1970s. Microsurgery. tissue reconstruction. J Reconstr Microsurg. 2003;
1993;14(1):6–13. 19(4):225–33.
 Phase IV: Late Reconstruction –
Abdominal/Chest Wall Closure
20
Whitney M. Guerrero and Timothy C. Fabian

20.1 D
 amage Control: Background in our experience, a much lower percentage of
for Laparotomy fascial approximation occurs following tempo-
rary abdominal closure. We attribute much of this
Damage control laparotomy is a mainstay of difference in closure rates to selection bias. If all
trauma surgery. The physiologic consequences of patients are managed with damage control lapa-
multiple devastating injuries often preclude rotomy and temporary abdominal closure, surely
definitive management of every injury at the most will ultimately allow for fascial closure
index operation. The threat of intra-abdominal because most could have been managed without
hypertension and the possibility of abdominal a temporary closure. If temporary abdominal clo-
compartment syndrome in the context of an sure is limited to the most severely injured
abdomen closed under tension make primary patients, it follows that fewer will be amenable to
abdominal closure at initial laparotomy unten- fascial closure during the same hospital stay.
able for some patients [1–5]. The most desirable Promotion of primary closure, of course, is the
outcome for the patient would be primary or best way to avoid having to manage a difficult
delayed primary closure during the index open abdomen.
hospitalization. Negative pressure is widely used to promote
Different centers have published approaches primary closure. Both the Barker vacuum pack
to the open abdomen. These techniques include technique (BVPT) and commercial negative
serial laparotomy followed by primary fascial pressure wound therapy (NPWT) devices may be
closure, bridged mesh closure, acute component used to this effect. In theory, vacuum mobiliza-
separation, or staged closure [2, 3, 6–8]. The pri- tion of the intraperitoneal fluid reduces retraction
mary goal across all approaches is to close the of the fascia and prevents loss of abdominal
abdomen as soon as is safe, keeping intra-­ domain.
abdominal pressure in mind. Another approach to increase the proportion of
Some institutions have reported fascial clo- patients who may be primarily closed is the use of
sure rates after damage control laparotomy with hypertonic saline (HTS), which in animal models
temporary abdominal closure of up to 90%, while has been shown to decrease visceral edema. A
study conducted by Harvin and colleagues
showed better rates of early primary ­ fascial
W.M. Guerrero (*) • T.C. Fabian
­closure (closure on or before post-injury day 7)
Department of Surgery, University of Tennessee
Health Science Center, Memphis, Tennessee, USA when HTS was administered. At the primary sur-
e-mail: wguerrer@uthsc.edu; tfabian@uthsc.edu geon’s discretion, patients with open ­abdomens

© Springer International Publishing AG 2017 207

H.-C. Pape et al. (eds.), Damage Control Management in the Polytrauma Patient,
DOI 10.1007/978-3-319-52429-0_20
208 W.M. Guerrero and T.C. Fabian

received 30 ml/h of 3% saline as maintenance flu- encountered therein, will be discussed in detail.
ids and were compared to a control cohort who Major overall complications include incidence of
received 125 ml/h of 0.9% saline. The HTS cohort mortality, fistula formation, and hernia
had a 96% primary closure rate compared to an recurrence.
80% primary closure rate for the normal saline
group (p < 0.001) [9]. There were limitations to 20.1.1.1 Stage One: Techniques
the study: it may be debated whether total fluid for Temporary Coverage
load may have had an effect, or whether perhaps of the Open Abdomen
sicker patients were excluded from the HTS The goal of the first stage of our approach is cov-
group at the discretion of the treating surgeon. erage of the abdominal viscera. At our institu-
Both infusion of greater than 5 L of crystalloid tion, the majority of our experience with coverage
and transfusion of packed red blood cells in has been with prosthetic materials. In the past,
excess of 10 units within the first 24 hours of polytetrafluoroethylene (PTFE) and polypropyl-
trauma are independent risk factors for abdominal ene sheets have been used, but these have long
compartment syndrome [10]. Fluid restriction in since fallen out of favor. PTFE is quite costly
a more general sense therefore can help reduce when used for temporary fascial closure.
the risk for intra-abdominal hypertension. Polypropylene sheets had been commonly used,
When primary or delayed primary closure is but showed an unfortunate propensity for the
impossible, it becomes necessary to consider the development of intestinal fistulae [13].
management of the giant ventral hernia. At Absorbable woven polyglactin 910 mesh is
Presley Regional Trauma Center in Memphis, the our prosthetic of choice. The mesh is applied as a
staged closure or planned ventral hernia approach bridge between fascial edges covering the
is favored [11]. DiCocco et al. reported, with abdominal viscera. Once this has been in place
excellent follow-up, a very low recurrence rate for approximately 1 week, an attempt at second-
(5% for PVH compared with 14% for all other ary fascial closure is routinely made: the prosthe-
methods) [12]. We will address the approach to sis may be pleated, sutured, and incised to
the staged closure in the remainder of this reapproximate the fascial edges. This is not pos-
chapter. sible in a substantial subset of patients; for these
individuals, the open wound is allowed to granu-
late and is covered with a split-thickness skin
20.1.1 Staged Management graft. Most patients have a fully granulated
of Abdominal Wall Defects wound after 2.5–3.5 weeks, and the mesh can be
removed without danger to the bowel. If the mesh
In the following sections, we will describe the is left in place for a prolonged time period, there
staged approach to the management of the com- is a significantly increased risk for intestinal fis-
plex open abdomen. This approach is employed tulae. Split-thickness skin grafts are therefore
in Memphis and was developed by Dr. Fabian placed as soon as an adequate granulation bed
and colleagues. When it is determined that fascial exists.
edges will not be approximated without undue
tension and the abdomen may not be closed in a 20.1.1.2 Stage Two: Building
traditional manner, our three-stage approach is the Planned Ventral Hernia
used. If pleating of the mesh is unsuccessful (as is the
The goal of Stage One is coverage: a biosyn- case for 75% of patients with temporary mesh
thetic replacement is inserted in the open abdom- closure), the open abdomen will require granula-
inal wall. Stage Two is the creation of a “planned tion and skin grafting, which are the basis of the
ventral hernia” (PVH), and Stage Three is the formation of a planned ventral hernia.
definitive takedown and reconstruction of the Intestinal fistulae are a dreaded complication
PVH. Each stage, as well as the complications in the management of the open abdomen and are
20  Phase IV: Late Reconstruction – Abdominal/Chest Wall Closure 209

most likely to occur during this stage. ing in inadvertent enterotomies and the accompa-
Approximately three quarters of intestinal fistu- nying increased risk of wound infection and
lae occur in the small bowel. They may be associ- reconstruction failure. Over time, however, these
ated with a failed suture line, but more often dense adhesions will resolve. On clinical exami-
result from erosion into the bowel by the mesh nation, the skin graft can be pinched away from
itself or at a site of breakdown in the granulation the underlying viscera with the fingers. When the
tissue bed. Our experience with utilization of two planes separate easily, reconstructions may
absorbable mesh followed by split-thickness skin be undertaken. There is a danger in waiting too
grafting has resulted in an 8% fistula rate in those long, as this can result in loss of abdominal
patients who survive the acute trauma. Analysis domain and higher rates of recurrence.
of those data allowed for the addressing of issues Abdominal wall reconstruction can be
of management techniques that might reduce the approached in two ways. The more popular of the
fistula rate [14]. two involves the use of permanent prosthetic
The risk of fistulae may be reduced by (1) materials. The appeal of this approach lies in its
avoiding nonabsorbable mesh, (2) approximating simplicity. However, infections of permanent
the fascia by pleating the absorbable mesh, and prosthetic materials pose a mammoth challenge,
(3) covering the granulation bed with a split-­ the treatment for which invariably involves
thickness skin graft in a timely manner. We have removal of the mesh. Follow-up care may span
discussed the first two points at length. To the months or years. Another approach, autologous
third point, an analysis of fistula development and tissue transfer circumvents this problem, but may
time to wound closure revealed that patients who pose another. If inadequate tissue exists for cov-
developed fistulae on average had their mesh in erage of the defect, hernia recurrence is more
place for 4 weeks, compared to 2.5 weeks for likely. Careful planning and meticulous tech-
patients who were successfully managed without nique can overcome the challenge of adequate
the development of a fistula. Thus, for patients tissue coverage and most hernia recurrence, while
whose wounds cannot be closed secondarily, even the best technique cannot prevent every
split-thickness skin grafting should be undertaken prosthetic infection. For these reasons, at our
as soon as possible. Once the bowel has adhered institution we favor autologous tissue transfer.
to the edges of the wound, the graft should be The component separation technique was
applied, and while fistulae can never be avoided devised by Ramirez and colleagues to repair
completely, careful adherence to these three prin- large abdominal wall hernias by tissue transfer
ciples can keep the fistula rate below 5%. [15]. In their description, the rectus abdominis
musculofascial unit is mobilized medially to
20.1.1.3 Stage Three: Definitive provide autologous continuity. Approximately
­
Reconstruction 5–8 cm can be mobilized with each musculofas-
The single most important factor in successful cial unit, but patients must be closely monitored
reconstruction of a planned ventral hernia is tim- for abdominal compartment syndrome for
ing. Extensive adhesions present a significant 24–48 h following repair. Standard component
obstacle to the completion of this operation. In separation may not offer enough tissue mobiliza-
our experience, it takes a full 6–12 months before tion to adequately cover the large defects that
these adhesions resolve to allow safe definitive may result from modern damage control lapa-
reconstruction. Patients must be followed long rotomy, necessitating the use of mesh. A tech-
term, and the resolution of adhesions may be nique was subsequently developed at our
assessed clinically. Soon after PVH formation, institution, which provides for closure of larger
adhesions between the viscera and the graft are defects, which ­cannot be closed by the standard
dense. The two planes cannot be separated on components separation. This reconstructive pro-
physical exam. An attempt to reconstruct at this cedure has been termed modified components
phase would be extremely difficult at best, result- separation [11].
210 W.M. Guerrero and T.C. Fabian

At our institution, approximately 50 patients 20 to 1800 cm2. Patients managed traditionally

per year are managed with temporary abdominal had a hernia recurrence rate approaching 20%,
closure after damage control laparotomy. In a while those managed with our staged approach
15-year review by DiCocco and colleagues in with modified component separation had a hernia
2010, more than 5000 trauma and more than 2500 recurrence rate of only 5% [12].
non-trauma laparotomies were performed during
the study period. Follow-up ranged from 9 months
to nearly 15 years. The majority of patients had a 20.1.2 Operative Approach
penetrating mechanism and the vast majority
were men. Most abdomens were left open due to In the operating room, the skin graft is pinched
visceral edema, and the defect sizes ranged from away from the underlying viscera somewhere
20  Phase IV: Late Reconstruction – Abdominal/Chest Wall Closure 211

near the midportion of the wound. The graft is the pubis inferiorly. Following division of the
sharply incised, and, with a combination of sharp external oblique component of the anterior rectus
and blunt dissection, it is dissected from the sheath, blunt dissection is carried out between the
underlying viscera. This excision generally takes external oblique fascia and the internal oblique
approximately 1 h. The most dense adhesions are fascia, bilaterally out to the area of the anterior
usually over the liver as well as at the native myo- axillary line to allow for mobilization of the rec-
fascial edge of the wound. It is imperative to gen- tus musculofascial component. Following divi-
tly dissect the adhesions from the liver, with sion of the external oblique fascia, the posterior
attention to avoiding dissection beneath Glissen’s rectus fascia is sharply dissected from the rectus
capsule, which results in significant troublesome abdominus muscles bilaterally. Care is taken to
oozing. The myofascial edge is virtually always avoid injury to the inferior epigastric vessels,
more densely adherent than the adhesions to the which provide blood supply to the rectus abdomi-
omentum or intestines. However, occasionally, nus muscles. For moderate-size defects, that may
small areas of dense adhesions to small bowel are be all of the mobilization required to allow for
encountered. Injury to the intestine may require fascial closure. However, most of the large
short areas of resection. Avoidance of permanent abdominal wall defects will require further sepa-
mesh for reconstruction is desirable due to the ration of abdominal wall components. The modi-
risk of infection of the foreign body. fication of the components’ separation description
The anatomy of the abdominal wall must be of Ramirez and colleagues that the author and
considered in understanding the mobilization and colleagues have added is to next divide the inter-
tissue transfer involved with modified compo- nal oblique component of the anterior rectus
nents separation. Both the anterior rectus fascia sheath. The location of the internal oblique com-
and the posterior rectus fascia comprise two ponent is readily seen after the external oblique
lamellae. The anterior rectus fascia is composed component of the anterior sheath has been
of an extension of the external oblique fascia divided. The internal oblique component is
combined with a component of the internal divided superiorly up over the lower costal mar-
oblique fascia. Thus, a fusion of the external gin, but it is very important to not divide it inferi-
oblique and a lamellum of the internal oblique orly below the linea semilunaris, because there is
fascia produces the anterior rectus sheath. The no posterior rectus sheath below that point. If the
posterior rectus fascia comprises the medial fas- internal oblique component of the anterior rectus
cia of the transverse abdominus muscle and the sheath were divided lower than the semilunar
posterior lamella of the internal oblique fascia. line, then a large hernia defect would be pro-
Thus, the internal oblique fascia splits to form a duced. The complete mobilization of these
component of both anterior rectus fascia and pos- abdominal wall components provides approxi-
terior rectus fascia above the accurate line. mately 10 cm of medial advancement in the epi-
Performance of the modified components sep- gastium, 20 cm in the mid-abdomen, and 8 cm in
aration technique begins with a division of the the lower abdomen. The epigastric region is
external oblique component of the anterior rectus always the tightest and is the most common loca-
sheath. The lateral plane where this division tion for the occasional need for adjunctive mesh.
occurs is located by grasping the rectus abdomi- Following these steps, the abdominal wall recon-
nus muscle between the thumb anteriorly and the struction is completed by approximating the
fingers posteriorly and squeezing this tissue; this medial edge of the posterior rectus sheath to the
allows for identification of the lateral portion of lateral portion of the anterior rectus sheath with
the anterior rectus fascia. This is approximately polypropylene suture. The repair is completed by
1 cm lateral to the lateral board of the rectus and reapproximating the medial edges of the anterior
is where the incision of the external oblique fas- rectus sheaths in the midline.
cia is begun. This incision is extended 6–8 cm Analysis of 73 patients who had definitive
above the costal margin superiorly and down to abdominal wall reconstruction using the modified
212 W.M. Guerrero and T.C. Fabian

components separation technique found that 5 years found that only 31 patients (4%) required
recurrent hernia developed in four patients (5%). damage control thoracotomy with a mortality
The mean follow-up of patients undergoing rate of 24% [18].
reconstruction was 24 months [12]. The author Thoracic compartment syndrome after thora-
and colleagues have discovered that waiting too cotomy is rare [19], but temporary closure of the
long for abdominal wall reconstruction produces chest wall may be undertaken. Methods of tem-
inferior results. When need for adjunctive mesh porary closure include closure of the skin only,
was grouped with hernia recurrence and they either suture or with towel clips [20], or the use of
were considered as complications, the complica- a Bogota Bag as employed in temporary abdomi-
tion rate was 7.6%. Patients with those complica- nal closure [21]. In addition, the thorax may be
tions were reconstructed at 20 months following packed to control hemorrhage [18], though there
discharge compared with 10 months in those is some controversy surrounding infection and
without complications. This is probably second- ventilatory restriction from intrathoracic packs
ary to progressive loss of abdominal domain and [22]. Vacuum-assisted closure devices may be
consequent closure under tension. Ideally, recon- employed to avoid thoracic compartment syn-
struction should take place when the skin graft drome [17].
can be pinched from the intestines; this is usually Concern for intrathoracic infection and venti-
the case within 6–12 months from initial hospital lator challenges from retained packing has led to
discharge. some reluctance to perform damage control oper-
ations analogous to those performed for the abdo-
men. In one study, 61 patients who required
20.1.3 Summary and Conclusion emergent thoracotomy for trauma either received
temporary chest closure with or without intratho-
The staged management of patients with giant racic packing (TCCP) or traditional definitive
abdominal wall hernias with autologous tissue chest wall closure (DEF). Concerns for infection
transfer using the Memphis modification of the and elevated peak airway pressures were not
component separation technique provides a safe borne out; TCCP showed no difference in infec-
and effective approach for initial management tion rate and actually lead to lower peak pres-
and definitive reconstruction. The rate of fistula sures on arrival to the intensive care unit. There
formation can be controlled using absorbable was no survival benefit observed for TCCP [23].
mesh and by covering granulating wounds early.
Reconstruction should be undertaken as soon as
resolution of dense adhesions allows. From the 20.2.1 A Note on Resuscitative
experience at the Presley Regional Trauma Thoracotomy
Center, the modified component separation tech-
nique is the procedure of choice for definitive While early experience with battlefield thoracot-
abdominal wall reconstruction. omies led to reluctance to perform the procedure
for fear of overwhelming infection [24], resusci-
tative thoracotomy (RT) has become an i­ mportant
20.2 Damage Control: part of the management algorithm for penetrating
Background trauma patients in extremis [25]. Though only
for Thoracotomy 1–2% of blunt trauma patients survive RT, 15%
of patients with penetrating thoracic wounds and
In contrast with damage control laparotomy, 35% of patients with penetrating cardiac wounds
damage control thoracotomy for severe thoracic survive [26]. The chest wall is routinely closed in
injury is performed infrequently with reported the operating room, though if concern for tho-
overall mortality of 20–40% [16, 17]. One review racic compartment syndrome arose, temporary
of 840 thoracotomies performed for trauma over closure techniques could certainly be used.
20  Phase IV: Late Reconstruction – Abdominal/Chest Wall Closure 213

20.2.2 Chest Wall Reconstruction skin graft. The omental flap is pedicled on the
gastroepiploic artery and may be fed through a
Whether from destructive penetrating injury or subcutaneous tunnel or via a transdiaphragmatic
massive blunt insult, trauma is a major cause of route – transdiaphragmatic is generally preferred
severe chest wall loss. Reconstruction may be as the subcutaneous tunnel results in a 21% inci-
required in the form of soft tissue coverage or dence of abdominal wall hernias [32]. The use of
fixation with soft and rigid materials [27]. an omental flap necessitates a laparotomy, and
Elements of both soft and rigid fixation may need the size and viability of a patient’s omentum is
to be employed to restore the best measure of variable [29].
functionality to the chest wall after severe trauma.

20.2.4 Rigid Fixation

20.2.3 Soft Tissue Injury
The goal of rigid fixation of the chest wall should
Acellular dermal matrices elicit a local inflam- be to restore structural integrity while preventing
matory response and may be an appropriate paradoxical motion during respiration. This is
choice for reconstruction. These can be stretched especially important for anterior chest wall
to span the defect and sutured directly to the rib defects [33]. To this end, a combination of lay-
to provide a degree of rigidity. Primary or flap ered dermal substitute, defect-spanning flexible
closure over the prosthesis is essential [27]. A plates, and muscle flap coverage has been
number of pedicled flaps have been described in described in the plastic surgery literature [34].
the context of surgical oncology, though these Surgical rib fixation is an acceptable way to
strategies may be reasonably applied to the cov- increase pulmonary function while decreasing
erage of a traumatic soft tissue defect. thoracic deformity, ventilator dependence, and
A pedicled latissimus flap developed for chest length of hospital stay [35–37]. Standard rib plates
wall reconstruction after mastectomy was are curved metal alloy. Some allow for intraopera-
described in 1906 [28]. This has been widely tive customization to better fit the individual rib
employed for traumatic soft tissue injuries. A curvature. These come in multiple sizes and are
latissimus flap allows coverage of most chest wall fixed to the rib either by intraosseous screws or by
defects; there is a large potential arc of rotation on clips that surround the rib. Multidirectional plates
a pedicle [29], and it is the most reliable choice are available for more complex defects. These
for coverage of the posterolateral chest and mid- allow for longitudinal and vertical stabilization of
back [30]. If necessary, one may use preoperative the rib cage if necessary [38]. Surgical rib stabili-
tissue expansion to improve coverage [29, 31]. zation is not without its complications. Infection
The pectoralis flap is the approach of choice is always a concern, and incidences of nerve
for superior anterior chest, sternal and cervical injury have been reported [39].
regions, and intrathoracic coverage. Rectus There is not at this time a widely accepted set
abdominis flaps, either free or pedicled, may be of indications for rib plating (save for flail chest
used for anterolateral and anterior chest wall as described above), and no defined algorithm for
defects. For back, posterior neck, and shoulder the timing of the procedure currently exists. Its
defects, the simple muscular or myocutaneous use is at the discretion of the surgeon.
trapezius flaps are frequently the simplest and
most cosmetic option [29].
Occasionally a chest wall defect will not be 20.2.5 Summary and Conclusion
amenable to coverage with an easily accessible
flap. The defect may be too large or may be sur- Thoracic compartment syndrome after resuscita-
rounded by damaged tissue. In this case, an tive or damage control thoracotomy is by no
omental flap may be used in conjunction with a means as frequently encountered as abdominal
214 W.M. Guerrero and T.C. Fabian

compartment syndrome, but it is a real entity that 14. Jernigan TW, et al. Staged management of giant

abdominal wall defects: acute and long-term results.
can have serious consequences for patients. Once
Ann Surg. 2003;238(3):349–55; discussion 355–7
the patient can tolerate it, there are multiple tech- 15. Ramirez OM, Ruas E, Dellon AL. “Components sep-
niques and approaches available for chest wall aration” method for closure of abdominal-wall
reconstruction; a touch of ingenuity on the part of defects: an anatomic and clinical study. Plast Reconstr
Surg. 1990;86(3):519–26.
the surgeon may be required for maximal restora-
16. Mackowski MJ, et al. Damage control for thoracic
tion of chest wall structure and function. trauma. Am Surg. 2014;80(9):910–3.
17. O’Connor JV, DuBose JJ, Scalea TM. Damage-­

control thoracic surgery: Management and outcomes.
J Trauma Acute Care Surg. 2014;77(5):660–5.
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Aesthet Surg. 2012;65(9):e253–6. 38. Kruger M, et al. Multidirectional thoracic wall stabili-
35. Zhang X, et al. Management of patients with flail zation: a new device on the scene. Ann Thorac Surg.
chest by surgical fixation using claw-type titanium 2013;96(5):1846–9.
plate. J Cardiothorac Surg. 2015;10:145. 39. Skedros JG, et al. Medial scapular winging associated
36. Xu JQ, et al. Better short-term efficacy of treating with rib fractures and plating corrected with pectoralis
severe flail chest with internal fixation surgery com- major transfer. Int J Surg Case Rep. 2014;
pared with conservative treatments. Eur J Med Res. 5(10):750–3.
2015;20:55.
 Part IV
Special Circumstances and Outcomes
 Principles of Damage Control
for Pelvic Ring Injuries
21
P.V. Giannoudis and Hans-Christoph Pape

21.1 Introduction the head, chest, and a­ bdomen may create compet-
ing actions between clinicians leading to unneces-
Pelvic fractures account for up to 8% of all skel- sary delays which can harm the patient.
etal fractures [1] and usually affect the adult pop- Appropriate assessment and treatment of all the
ulation. They present after high-energy trauma injuries therefore is crucial and can lead in fewer
with car and motorcycle accidents being the most deaths and less long-term disability.
common mechanism of injury. Pelvic fractures in The diversity of pelvic ring disruptions led to
the elderly population are secondary to low-­ the development of different classification sys-
energy trauma and in a sense represent a different tems over the years based on fracture location,
entity. For this reason, their management will not pelvic stability, injury mechanism, and direction
be covered in this chapter. of injury force applied. Nowadays, the Young and
While the establishment of national and Burgess classification system, which classifies the
regional organized trauma systems has contrib- fractures according to the direction of the force
uted to a more unified management of these severe applied during the course of the accident (ante-
injured patients, pelvic ring disruptions continue rior-posterior compression (APC), lateral com-
to be a substantial source of morbidity and mor- pression (LC), vertical shear (VS), and combined
tality [2]. In the emergency setting, the manage- mechanical injury (CMI)), continues to be used
ment of patients with pelvic fractures remains extensively in the clinical setting [3]. This can be
perplexing requiring the input of d­ ifferent special- attributed to the fact that it allows detection of the
ties and leadership skills to take promptly difficult posterior ring injury and predicts local and distant
decisions. The presence of associated injuries to associated injuries, resuscitation needs, and
expected rates of mortality. The most severe pat-
terns of injuries within the subgroups created
P.V. Giannoudis, MD, FACS, FRCS (*) APC III, LC III, vertical shear (VS), and com-
Academic Departments of Trauma and Orthopaedic
Surgery, School of Medicine, Leeds General bined mechanical injuries are suggestive of major
Infirmary University Hospital, University of Leeds, ligament disruption. These most severe injury pat-
Leeds LS1 3EX, UK terns, for instance, the APIII, require the most
e-mail: pgiannoudi@aol.com blood replacement, followed by VS, followed by
H.-C. Pape, MD, FACS CM, followed by LC III injury patterns [3].
Professor and Chairman, Department of Trauma, Patients with pelvic fractures could be divided
Zurich University, Raemistr. 100,
8091 Zurich, Switzerland into two distinct subgroups. In the first group of
e-mail: papehc@aol.com patients, usually stable pelvic fractures with most

© Springer International Publishing AG 2017 219

H.-C. Pape et al. (eds.), Damage Control Management in the Polytrauma Patient,
DOI 10.1007/978-3-319-52429-0_21
220 P.V. Giannoudis and H.-C. Pape

of the injury confined to the ligamentous tissues “chimney effect” [6]. Exsanguination and/or
are present. The management approach in these pelvic and abdominal compartment syndrome
circumstances is focused on the restoration of the may ensue. According to Heetveld et al. every
osteo-ligamentous structures on a more semi-­ 3 min of hemodynamic instability without
elected basis. In the second group, displaced pel- ­hemorrhage control increases the mortality by
vic ring fracture is a common finding necessitating 1% [7].
emergency hemorrhage control and a multidisci- In general terms, the principles of physiologi-
plinary team approach for the other organ system cal state classification applied for patients with
injuries. Noteworthy, the prevalence of pelvic multiple injuries also are valid for those with pel-
fractures presenting with hemodynamic instabil- vic fractures. Four different categories have been
ity has been described to range from as low as 2% identified as follows [8]:
up to 20% [2, 4]. Early recognition and appropri-
ate clinician decisions in this group of patients (a) Stable (no clinical signs of shock, no chest
can hence provide significant improvements in trauma)
outcome. (b) Borderline (systolic blood pressure
The management of this cohort of patients 80–100 mmHg, chest AIS 2 or more, blood
possessing the highest risk of early and late com- transfusion 2–8/2 h, and other criteria)
plications and mortality has advanced over the (c) Unstable (dropping or undulating systolic
years to what is known today as “damage control blood pressure of >90 mmHg, pulse of <100
orthopedics.” beats/min, chest AIS 2 or more, CVP
>5 cmH2O, urine output of >30 ml/h despite
adequate fluid resuscitation, and blood trans-
21.2 I mpact of Pelvic Injuries fusion over a period of 2 h)
on the Hospital Course (d) In extremis (patients with either absent vital
signs or presence of severe shock due to
21.2.1 Influence of Pelvic uncontrollable hemorrhage needing mechan-
Hemorrhage ical resuscitation or repeatedly catechol-
amine infusion, despite complete blood
In patients with high-energy injuries, quick iden- volume replacement within 120 min (>12
tification of hemorrhage related to the pelvic blood transfusions/2 h))
injury in the hemodynamically unstable patient is
both critical and time-dependent. As a rule of thumb, the initial management
Arterial bleeding (iliac vessels and their focuses on hemorrhage control. Thus, complex
branches to the inferior abdominal viscera and reconstructions are delayed until the patient is
pelvic organs) is a major contributor to hemor- hemodynamically stable and in a better physio-
rhagic shock in pelvic fractures. Other sources logical condition to withstand the additional sur-
of bleeding include the venous plexus and frac- gical burden. Avoidance of coagulation
tured cancellous bone surfaces. These are usu- disturbances, systemic inflammatory response,
ally low-­pressure bleedings and they leak into adult respiratory distress syndrome, and multiple
the retroperitoneal space. The retroperitoneum organ dysfunction syndrome is of paramount
can contain several liters of blood and bleeding importance for reduced mortality rates.
may continue even after that. Thereby, Hemorrhage may occur from external or inter-
­uncontrolled hemorrhage may develop, as the nal bleeding: For external bleeding, the main
retroperitoneal space does not allow for self- maneuver consists of application of direct pres-
tamponade [5]. This can lead to constant further sure and rapid surgery. In internal bleedings, it
hemorrhage creeping proximally around and has to be decided whether angiography and
above the psoas muscle or along the gluteal embolization is required or whether packing of
muscles. This phenomenon has been named the the extraperitoneal space is favored [9].
21  Principles of Damage Control for Pelvic Ring Injuries 221

21.2.2 Initial Assessment

The first step in the treatment of restoring hemody-

namic stability includes the administration of intra-
venous crystalloid fluids and whole blood. When
replacement of fluid and blood does not stabilize
the patient’s vital signs, additional steps must be
taken. Any subsequent interventions should be
rapid and minimally traumatic focusing on hemor-
rhage control and other lifesaving measures.
In hemodynamically unstable patients with no
obvious site of hemorrhage, careful clinical
examination of the pelvis is mandatory even
when radiographs look normal or a pelvic image
demonstrates a stable fracture configuration.
Physical examination of the pelvis should include
thorough inspection of the flanks, lower abdo-
men, groin, perineum, and buttocks to detect any
wounds or bruises. Injuries to cervix, uterus, and
ovaries are rare [8]. Inspection of the external
genitalia is the first action to take, and then, a
more meticulous digital examination can reveal:
lacerations, blood at the external urethral meatus,
a high-riding prostate, perineal h­ ematoma, hema- Fig. 21.1  Scrotal swelling following pelvic trauma
turia, and vaginal bleeding (Fig. 21.1). Any of
these findings or the inability to urinate in asso-
ciation to an anterior pelvic ring fracture should
be an indication for retrograde urethrogram [10];
a cystogram should f­ ollow through a suprapubic
catheter, if a u­ rethral injury has been diagnosed.
In this way, we can assess both the urethral and
bladder integrity (Fig. 21.2).

21.2.3 Radiographic Assessment

The basic radiographic examination includes a

pelvic X-ray in most institutions. While in previ-
ous recommendations, inlet (beam directed cau-
dad at 60°), outlet (beam directed cephalad at
45°),83 and Judet (iliac and obturator oblique)
pelvic radiographs have been advocated, this is Fig. 21.2  AP pelvic radiograph (complex pelvic and ace-
no longer the rule in level I trauma centers, where tabular fracture) illustrating the acquisition of a retrograde
a CT scan is done anyway and a 3D reconstruc- cystogram (arrow)
tion can be obtained through free software
options [11]. If there is no CT option, and if the It is of note that in stable patients the useful-
pelvic plain film shows a pelvic fracture, there is ness of a pelvic X-ray (PXR) has been ques-
a 50% probability of retroperitoneal bleeding. tioned, as it was discussed to detect only
222 P.V. Giannoudis and H.-C. Pape

66–87% of pelvic fractures [11]. Moreover, the 21.3 C

 ontrol of Mechanical Pelvic
X-ray may miss non-bony pelvic injuries. Instability and Hemorrhage
However, for the unstable blunt trauma patient,
the pelvic radiograph is necessary because The nature of the pelvic fracture, whether closed
these patients can neither provide a reliable or open, and the hemodynamic status of the
physical examination nor undergo immediate patient will determine the treatment plan. In
CT scan. As a result, PXR provides a useful unstable patients, apart from the fluid resuscita-
gross estimate of pelvic injury. Moreover, as tion and administration of appropriate pharma-
would be expected, in unstable pelvic fracture cotherapy targeting the clotting cascade (i.e.,
patterns, sensitivities of the plain film administration of tranexamic acid) [13], there is
are improved over minor pelvic fractures, a need to enhance the tamponade effect in the
75–91% [11]. pelvis in order to increase the intrapelvic pres-
The fracture pattern on the initial anterior-­ sure and to facilitate hemostasis. This can be
posterior pelvic X-ray is the best initial guide to achieved by either invasive or noninvasive
determine the probability of pelvic arterial measures.
bleeding. As mentioned above, the Young and
Burgess classification system has been utilized
more frequently than the Tile system when 21.3.1 Noninvasive Measures
comparing the potential association between
pelvic fracture type and retroperitoneal The noninvasive techniques are usually applied
­hemorrhage [12]. on scene or in the emergency room as soon as a
A significant correlation has been reported diagnosis is available. They include application of
between greater blood product requirement and a circumferential sheet, pelvic binder, internal
unstable fracture patterns. However, a limitation rotation of both legs, traction of the lower limbs,
of predicting hemorrhage based on classifying and application of military antishock trousers
the initial pelvic X-ray is that major posterior ele- (MAST).
ment disruption may not be detected in 9–22% of Direct pelvic compression can be applied
fractures when compared with CT. using a bedsheet, a pelvic sling (Fig. 21.3), or a

Fig. 21.3 Application
of pelvic sling in a
patient with multiple
injuries
21  Principles of Damage Control for Pelvic Ring Injuries 223

21.3.2 Invasive Measures

21.3.2.1  rterial Inflow Arrest: Arterial

A
Occlusion and Cross Clamping
In cases that rapid exsanguination of the patient
is imminent, occlusion of the aorta can be used as
a temporary measure to control the hemorrhage
[21]. This can be performed directly by open
cross clamping [22] or via percutaneous or open
balloon catheter techniques [23]. Other authors
have reported satisfactory control of arterial
bleeding with ligation of the hypogastric artery
attributing this to the remarkable collateral sup-
Fig. 21.4  Application of pelvic binder
ply within the pelvis [24].

commercially available pelvic belt (Fig. 21.4). 21.3.2.2 External Fixation

By each of them, satisfactory pelvic compression The anterior fixator has been shown to contribute
appears to be achievable without limiting access to hemostasis by maintaining a reduced pelvic
to the patient [14–16]. volume, allowing tamponade, and by decreasing
Vermeulen et al. first illustrated the prehos- bony motion at the fracture site, thus allowing
pital use of an external pelvic compression clots to stabilize (Fig. 21.5) [8].
belt (Geneva belt) in a series of 19 patients in
1999 [17]. Their device was applied by para-
medics at the accident scene as soon as there
was a clinical suspicion of unstable pelvic
fractures. The area of application is usually at
the level of greater trochanters/symphysis
pubis directly on to the patient’s skin. It has
been suggested that the force required to
reduce unstable open book pelvic fractures is
around 180 N based on cadaveric models. This
led to the development of new commercial
splints (SAMsling, SAM Medical Products
TM, Oregon, USA), which use controlled and
consistent stabilization with an autostop
buckle to reduce the risk of overcompression
in internal rotation injuries [18]. It has been
shown that simple application of this sling
increases pelvic stability by 61% in response
to rotational stress and 55%, flexion–exten-
sion [19, 20].
Clinical judgment and reassessment are
important in using these techniques. Potential
complications include skin necrosis if left in
place too long or applied too tightly. In lateral
compression injuries with transforaminal sacral
fractures, possible visceral or neural injury may Fig. 21.5 Application of anterior external fixator –
occur if applied too vigorously. A-frame configuration prior to laparotomy
224 P.V. Giannoudis and H.-C. Pape

In the emergency situation, external stabiliza- left in place for several days and does not cause
tion of the pelvis indeed becomes the first prior- soft tissue issues as reported with pelvic slings.
ity. In many instances, external fixation replaces These issues are listed in Table 21.2.
the stability achieved by a pelvic sling or a pelvic These clamps have been applied in hemody-
binder. namically unstable patients and prophylacti-
It has been discussed that optimal results are cally in stable patients with unstable pelvic ring
achieved in rotationally unstable LC fracture types disruptions. Their use is, however, limited to a
II and III and APC types II and III. Stabilization specific set of indications, for example, they are
can be achieved in 64–83% of these fractures [25]. not applicable in fractures of the ilium and
With additional vertical instability (VS or CM trans-iliac fracture dislocations. Complications
type injury), stabilization can be achieved in only include potential injury to gluteal neurovascu-
27% of cases, and supplementary ipsilateral skel- lar structures and overcompression with the
etal traction is needed [26, 27]. risk of secondary nerve injury in sacral frac-
The fixation can either be achieved using the tures [30].
anterior superior iliac crest or the supraacetabular Although potentially lifesaving, these devices
region. Both localizations have advantages and should be applied by an experienced surgeon and
disadvantages, as listed in Table 21.1. considered only in cases of posteriorly unstable
Briefly, the anterior superior pelvic crest is pelvic fractures accompanied by hemodynamic
easily accessible and allows for quick fixation. instability.
However, it may be subject to loosening
because of the thin layer of bony attachment. 21.3.2.3 Acute Fracture Fixation
Recently, a percutaneous technique has become Provisional fixation of unstable pelvic ring
available that might be an alternative. At this disruptions with a pelvic clamp or an external
stage, however, no data is available in frame with a supracondylar pin has proven
larger series, and it is used in certain institu- markedly beneficial in the resuscitative phase
tions only [28]. of management [31]. If, however, the patient
In type C or open book fractures, external fix- undergoes a laparotomy to deal with visceral
ator constructs appear to demonstrate a high rate injuries, symphyseal disruption and medial
of secondary displacement. In these fracture ramus fractures should be plated at the same
types, additional posterior fixation is required in time. Because neither blood loss nor operative
order to provide a stable construct. Ganz et al. time is greatly increased, combining these
developed a large external fixation device that repairs decreases the risk of complications in
connects to the pelvis in the area adjacent to the a patient who is already compromised [32].
sacrum and is thought to reduce the iliac wing A role has also been suggested for percutane-
toward the sacrum [29] (Fig. 21.6). As it applies ous fixation; however, only surgeons appropriately
sustained forces, it is able to provide a counter- trained should use this technique. Percutaneous
acting force for pelvic packing. Also, it can be pelvic fixation techniques allow for acute and

Table 21.1  Advantages and disadvantages of stabilization of the pelvic ring with anterior pelvic fixator using either
the anterior superior iliac crest or the supraacetabulum area
Anterior superior pelvic
crest Supraacetabular external Percutaneous
Advantages Easily accessible Good purchase, allows for one Excellent fixation, no soft
Schanz pin only tissue problems
Disadvantages May be subject to early Trend toward more radiological Time to fixation might be
loosening assessment increased
Requires multiple pins Soft tissue issues in obese
patients
21  Principles of Damage Control for Pelvic Ring Injuries 225

a b

Fig. 21.6 (a) Application of C-clamp. (b) AP pelvic radiograph demonstrating stabilization of the posterior ring with
the C-clamp

Table 21.2  Advantages and disadvantages between pelvic C-clamp and pelvic sling (binder) for temporary ­stabilization
of the posterior pelvic elements
Pelvic sling Pelvic C-clamp
Advantages Allows for prehospital placement Provides excellent stability
Does not require immediate X-ray control Allows for pelvic packing
Disadvantages Soft tissue necrosis in prolonged use Pin tract issues in concomitant acetabular
Frequent malplacement by paramedics fractures requiring posterior approaches
May cause overcompression in case of sacral Displacement and overcompression issues if
crush injuries used without proper radiologic control

definitive treatment of anterior and ­posterior pel- Nevertheless, in the acute setting and espe-
vic ring injuries, without extensive dissection [33]. cially in the “extremis” clinical condition of the
Fixation can be performed acutely, even as a patient, such an approach is not advocated as it is
component of the patient’s resuscitation. Operative time consuming, and often extensile approaches
blood loss is minimal and wound complications are are necessary predisposing the patient to uncon-
unusual. Minimally invasive anterior ring fixation trollable hemorrhage, coagulation disturbances,
includes external fixation with retrograde or antero- and early mortality.
grade screws in the medulla of the superior ramus.
Closed reduction and fixation with percutaneous 21.3.2.4 Pelvic Angiography
sacroiliac screws offers definitive stable fixation for and Embolization
many posterior pelvic ring injuries, such as frac- Information about the rate of arterial injury
ture/dislocation of the sacroiliac joint or sacral in pelvic trauma has primarily been derived
fractures, with the advantage of minimal dissection from angiographic studies, with reported rates
and a reduction in wound complications. ranging from 0.01% to 2.3% for all pelvic
­
226 P.V. Giannoudis and H.-C. Pape

trauma and from 9% to 80% in unstable pelvic do not have angiographic capabilities, hence
injuries [5, 34]. necessitating transfer of any such patient – not
Timely identification and control of pelvic an ideal option in the already hemodynami-
hemorrhage is pivotal to decrease pelvic fracture-­ cally unstable patient.
related mortality. The main controversy regard- Current consensus is that before angiography,
ing the treatment of patients with profuse, aggressive resuscitation needs to be initiated;
exsanguinating hemorrhage relates to the role of other sources of bleeding (chest/abdominal) need
angiography and embolization. This technique is to be ruled out, and provisional pelvic stabiliza-
time consuming and can be performed in only tion with either a sheet or external fixator should
approximately 10% of the cases [35]. be performed. If the patient remains hypotensive,
Simultaneous treatment of other injuries can- angiography is indicated [5].
not be performed during this procedure, and mor-
tality of up to 50% has already been reported, 21.3.2.5 Pelvic Packing
despite effective bleeding control [36]. Where ongoing hemodynamic instability is
Angiography requires skilled radiologist and encountered, pelvic packing can complement the
technical staff as well as transportation of a criti- external fixation (Fig. 21.7). It is effectuated
cally ill patient to the angio-suite knowing that through a lower abdominal laparotomy, adjusted
there have been series where 20% of these to the pelvic wound. Packs have to be inserted in
patients had cardiorespiratory arrest during the the prevesical and presacral spaces and have to be
procedure [36]. removed or changed within 48 h [42]. Abdominal
However, in a hospital where interventional injuries are simultaneously assessed and treated.
radiology is available, angiography is both diagnos- In some European centers, external fixation of
tic and therapeutic for pelvic hemorrhage [37, 38]. the pelvic fracture and surgical packing of the
Indeed, early angiography and embolization retroperitoneum is performed in favor of angiog-
has proven to be one of the most important inter- raphy [5].
ventions to control arterial pelvic hemorrhage [5, Pelvic packing (PP) eliminates the often
37, 38]. In recent and prospective series, early arduous decision by the trauma surgeon: OR
diagnostic angiography has revealed arterial versus IR? All patients can be rapidly trans-
injury or bleeding following pelvic fractures in ported to the operating room, and PP can be
44–76% of hemodynamically unstable pelvic accomplished in less than 30 min. It may be also
fracture patients [39–41]. ideally suited for austere conditions and in set-
Extravasation of contrast, false aneurysms, tings where angiography is unavailable or
and occlusion due to thrombus or vasospasm are
all signs of arterial injury, which may require
embolization. Overall, embolization is safe and
effective and achieves up to 90% success rates
[39–41].
Nevertheless, there are several aspects of the
current management strategy of early angioem-
bolization for hemodynamically unstable patients
with pelvic fractures that are concerning.
Predicting the patient who does or does not
require embolization remains a challenge.
Secondly, although angioembolization may be
effective in controlling pelvic arterial bleed-
ing, it has not been shown to decrease the
necessity for blood product resuscitation. Fig. 21.7  Changing of pelvic packs 48 h after laparot-
Third, there are a number of institutions that omy where packing was applied
21  Principles of Damage Control for Pelvic Ring Injuries 227

unable to be done e­ xpeditiously. Emergent ret- Angiographic embolization is not usually

roperitoneal packing appears to be a safe proce- indicated in this patient population. However,
dure that has a role in damage control of in cases where hemodynamic stability with
critically injured patients. It can be done imme- volume replacement can be achieved but
diately and with ease in conjunction with exter- ongoing pelvic hemorrhage is suspected
­
nal fixation of the pelvis and other surgical (expanding hematoma), then angiography
procedures to stabilize the patient. could be ­considered as an adjunct to the treat-
ment protocol.
In general terms the criteria to apply the
21.4 Damage Control DCO principle are shown in Table 21.3. DCO
Orthopedics for Pelvic in practice consists of different stages,
Fractures including: resuscitation, hemorrhage control,
­
with Hemodynamic decompression, decontamination, fracture
­
Instability splintage, and prompt transfer to the intensive
care unit where close monitoring of all the vital
In patients with pelvic fractures being in an “unsta- organs can take place and resuscitation can
ble” or “extremis” clinical condition, prolonged continue until physiological normality has been
operative interventions could initiate a series of achieved [8].
reactions at the molecular level predisposing the These principles are adapted to the pelvis as
patient to an adverse outcome. Any surgical inter- shown in Table 21.4.
vention here must be considered immediately life- During the resuscitation phase, it is essen-
saving and should therefore be simple, quick, and tial to appreciate that in the patient with sig-
well performed. Rigid rules relating to timing nificant ongoing blood loss, ratios of blood
should be avoided to prevent unnecessary delay – products similar to whole blood will be
time is usually critical to survival of the patient [43]. required to reach simultaneously acceptable
Protocols designed to reduce mortality should levels of hematocrit, clotting factor concentra-
stop bleeding, detect and control associated inju- tion, and platelet count. The need of having in-
ries, and restore hemodynamics. A staged diag- house massive transfusion protocols is
nostic and therapeutic approach is required. The therefore of paramount importance in order to
severity of bleeding is a crucial hallmark for sur- be able to deal efficiently with increased
vival during the early period after injury. resuscitation requirements. Nunez TC et al.
­
Numerous clinical pathways were devel- ­developed a score to assist clinicians to predict
oped and published during the last 20 years for the need for activation of a massive blood
management of hemodynamically unstable transfusion protocol. The authors identified
patients. All of them consist of abdominal four parameters (systolic blood pressure
diagnostics, pelvic binding and/or external fix- (<90 mmHg), heart rate (120 bpm), penetrating
ation, pelvic retroperitoneal packing, angioem- mechanism, and positive fluid on abdominal
bolization, and orthopedic fixation of the
pelvis. Table 21.3  DCO criteria for application in p­ elvic ring
Because of the disastrous sequelae of uncon- injuriwa
trolled hemorrhage in young patients, only exter- Criteria for application of DCO for pelvic fractures
nal devices that are easy to apply can be used Hypothermia < 34 °C
effectively. These devices, by external compres- Acidosis pH <7.2, serum
sion, reduce the intrapelvic volume and create a Lactate >5 mmol/L
tamponade effect against ongoing bleeding. Coagulopathy
Pelvic packing should be considered in cases Blood pressure <70 mmHg
where, despite the application of the external Transfusion approaching 15 units
­fixator, ongoing bleeding is encountered. Injury severity score >36
228 P.V. Giannoudis and H.-C. Pape

Table 21.4  Integration of the DC concept into the management of pelvic ring injuries

Patient status

Primary
Assessment Borderline Unstable In extremis
(e.g. ED)

RESUSCITATION RESUSCITATION
Severe organ injury (head, chest, pelvis) Monitoring:

Pelvic stabilization:
Secondary Exfix/packing/
Assessment Stable Borderline Unstable Angiography
(e.g.prior
Surgery)

Provisional DCO
external fixation

RESUSCITATION AND
STABILIZATION OF THE
PATIENT
kk
Tertiary kn
Assessment
(e.g. 24 h post-
Stable Borderline
trauma)

repeated
reevaluation
and
adaptation
of surgical
treatment

ORIF ORIF Definitive surgery once patient has

Pelvis Pelvis stabilized

ultrasound) and assigned a score of 1 to each chest cavity. Any additional interventions
one if present. They reported that a score of 2 (decompression of cavities, i.e., intracranial hem-
predicts 38%; a score of 3, 45%; and a score of orrhage) and decontamination (irrigation and
4, 100% the need of massive transfusion [44]. debridement of open wounds) should be per-
For the hemorrhage control, different options formed as quickly and efficiently as possible try-
to stop the bleeding from the pelvic ring were ing to avoid time-consuming procedures.
previously discussed. Moreover, prompt identifi- Associated fractures to the extremities can be
cation of other sources of bleeding should also managed promptly by the use of external fixators
take place particularly from the abdominal and for temporarily stabilization followed by delayed
21  Principles of Damage Control for Pelvic Ring Injuries 229

definitive reconstruction when the patient has washout, either free flow or pulsed lavage tech-
overcome the initial physiological crisis phase niques can be used. The wounds can either be left
and can tolerate well the surgical stress of pro- open or vacuum-sealed dressings can be used in
longed reconstruction procedures. order to drain them. A second look, with or with-
out closure, should be effectuated after 48–72 h
[51, 52, 53].
21.4.1 Ongoing Treatment The possibility of a compartment syndrome
associated to the abovementioned injuries
If definitive stabilization is needed, it should be shouldn’t be neglected. The major pelvic com-
effectuated according to the principles of “dam- partments are the iliopsoas, the gluteus maximus,
age control orthopedics” [8]. Definitive stabiliza- and the gluteus medius/minimus. Measurement
tion in closed pelvic fractures with internal of their pressure is mandatory. Plastic surgical
fixation is recommended between the third and techniques can be undertaken in order to treat
seventh day post-injury [8]. In open fractures, the these wounds and eliminate dead spaces. Split- or
timing is not adequately covered and fixation full-thickness skin grafts are used as well as suc-
techniques are controversial. Traditionally, only tion drains, vacuum-sealed drainage, or free flaps
external fixation has been used, but there are (Fig. 21.9).
authors publishing good results after internal fix- The management of the open pelvic fracture
ation [45] or suggesting internal fixation when should follow the same guidelines and principles
there is no gross contamination of the fracture as for any open fracture of the extremities. The
site [46]. In comminuted iliac wing fractures, perineal wounds must be judged (because of their
early open internal fixation is preferred since location) for a potential contamination of the
external fixation cannot be applied [47]. fracture site and/or of the retroperitoneal hema-
Combination of internal and external fixation has toma. Perineal wounds involving or not the rec-
been described by Leenen et al. [48], and percu- tum require fecal diversion, early sphincter repair
taneous internal fixation has been used for open (when injured), and local wound management
fractures with less complications [49]. [54]. When placing the stoma, we should bear in
When wounds are associated to the pelvic mind the eventual location of any orthopedic
fractures, their treatment includes extensive irri- incision, suprapubic catheter, and external fixator
gation, debridement (up to healthy tissue with pins. The restoration of the continuity has an
capillary bleeding) and removal of foreign bodies
and bony fragments (Fig. 21.8) [50]. For the

Fig. 21.8  Pelvic fracture with perianal laceration (arrow) Fig. 21.9  Application of vac pack to open wound –
and laceration to left buttock region ­pelvic fracture stabilized with anterior external fixator
230 P.V. Giannoudis and H.-C. Pape

important rate of complications, and therefore include problems with wound healing, soft tissue
awareness of the patient with regard to this issue and skin flap necrosis, iliopsoas necrosis from
is of paramount importance [54]. avulsion of its blood supply, local infection lead-
In “complex” pelvic and acetabular fractures, ing to lethal systemic sepsis, and meningitis
perineal soft tissue swelling and “butterfly” hema- probably secondary to ascending infection along
toma is frequently present. This is the result of the the avulsed lumbar and sacral roots [58].
extravasation of the retroperitoneal hematoma
through the superficial perineal fascia of Colles. It Conclusion
can be managed with a scrotal sling for 5–7 days Pelvic fractures in high-energy trauma are
and then with a triangular sponge wedge (usually usually associated with hemorrhagic shock.
after surgical management of the lesions) [55]. Early hemodynamic stabilization is of capital
Surgical insult to the perineum, local venous importance and should be taken into account
thrombosis, the pudendal post during skeletal trac- starting from the prehospital care of the
tion, transient hypoalbuminemic state, and scrotal injured. Patients need to be managed in a syn-
skin breakdown with sloughing and local infection chronous fashion by a multidisciplinary team
can contribute to the expansion of the swelling. upon their admission to the trauma center.
When a pelvic fracture is suspected, temporar-
ily stabilization should be attempted before
21.5 Special Situations admission. The hemodynamic and pelvic sta-
bility, primarily, and the associated injuries
21.5.1 Hemipelvectomy will determine the sequence of management.
The early adequate treatment of the pelvic
A particular type of pelvic injury is that of the fractures, starting from the hemodynamic
hemipelvectomy. This can be defined as an unsta- parameters, decreases the mortality and
ble ligamentous or osseous hemipelvic injury improves the outcome. The concept of dam-
with rupture of the pelvic neurovascular bundle. age control orthopedics for pelvic fractures
Usually it is characterized by wide separation of should be considered in borderline patients
the pubic symphysis and the sacroiliac joint, with that do not respond to resuscitation. It should
various degrees of soft tissue and neurovascular be applied in patients in an unstable and extre-
disruption and stretching. The nonviable limb mis physiological state (Table 21.4) [59].
may still be attached to the trunk. Simultaneous
and not sequential care is mandatory. Only in
stable patients we can proceed to pelvic X-ray, References
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 Principles of Damage Control
for Pediatric Trauma
22
Christine M. Leeper, Andrew Peitzman,
and Barbara A. Gaines

22.1 Introduction syndrome, and delayed closure after resuscitation

and stabilization. The effect of this strategy was
Pediatric general surgery has embraced the con- to improve survival and decrease morbidity in
cept of “damage control” operations as the stan- critically ill neonates with a range of pathology
dard of care for decades, though not necessarily (gastroschisis, necrotizing enterocolitis, midgut
by name. Temporary abdominal wall closure has volvulus, etc.). The use of damage control prin-
been utilized by pediatric surgeons in the man- ciples for the management of trauma followed
agement of congenital abdominal wall defects later as this practice increased in popularity for
since first described by Schuster in 1967 [1]. The the management of injured adults.
use of prosthetic material for coverage of abdom- The main tenets of damage control are the
inal contents allowed for second-look proce- same in pediatric patients as in adult patients:
dures, avoidance of abdominal compartment minimize iatrogenic injury (hypothermia, hemo-
dilution), address shock and coagulopathy with
appropriate resuscitation, and achieve rapid sur-
C.M. Leeper, MD, MS gical control of bleeding and fecal stream with
Department of Pediatric General and Thoracic delayed definitive closure if necessary. However,
Surgery, Children’s Hospital of Pittsburgh of UPMC,
children have important anatomic and physio-
Pittsburgh, Pennsylvania, USA
logic differences that require adaptation of or
Division of General Surgery and Trauma, Department
occasional divergence from adult damage control
of Surgery, University of Pittsburgh Medical Center,
Pittsburgh, Pennsylvania, USA practices.
A. Peitzman, MD
Division of General Surgery and Trauma, Department
of Surgery, University of Pittsburgh Medical Center, 22.2 E
 pidemiology of Trauma
Pittsburgh, Pennsylvania, USA in Children
e-mail: peitzmanab@upmc.edu
B.A. Gaines, MD (*) Trauma is the leading cause of death for chil-
Department of Pediatric General and Thoracic
dren and adolescents in the United States [2], as
Surgery, Children’s Hospital of Pittsburgh of UPMC,
Pittsburgh, Pennsylvania, USA well as a source of tremendous morbidity and
e-mail: gainesba@upmc.edu cost to patients, families, and society [3]. More

© Springer International Publishing AG 2017 233

H.-C. Pape et al. (eds.), Damage Control Management in the Polytrauma Patient,
DOI 10.1007/978-3-319-52429-0_22
234 C.M. Leeper et al.

than 90% of pediatric trauma is attributed to which can result in increased head injury ­severity
blunt force trauma, whereby the most frequent from a comparable blow. The smaller shape and
mechanism of injury in the children is falls; size of the pediatric patient’s body predisposes
however, the most common cause of death is them to multiple injuries and increased severity
motor vehicle crash (MVC). The remaining of injuries, as the energy from traumatic incident
10% of pediatric injuries are attributed to pene- will generate a much larger force compared to
trating trauma, of which firearm injuries are the adult patient. Children have decreased mus-
most lethal. Penetrating injuries are associated culature and subcutaneous tissue as compared to
with a threefold higher mortality rate as com- adults. As a result, the liver and spleen are
pared to blunt trauma, with up to 70% of located more anteriorly in the abdomen, and the
deaths occurring prior to hospital arrival [4]. kidney is more mobile, which places these
Hemorrhagic injuries are much less prominent organs at greater risk of injury from abdominal
in pediatric patients, with traumatic brain injury trauma [6].
being the number one source of morbidity and
mortality in injured children [5].
22.3.2 Hemodynamics

22.3 Special Considerations: Unlike adults, children are usually healthy at

Pediatric Anatomy the time of trauma and are rarely on medica-
and Physiology tions that affect hemostasis or hemodynamics
[7]. They have outstanding early compensatory
Clinicians often extrapolate best practice from mechanisms that allow for the loss of up to
the adult trauma management guidelines; how- 45% of their circulating blood volume before
ever, this can be problematic as a still-developing becoming hypotensive [8]. Hypotension is
child’s anatomy and physiology can vary dra- therefore a late sign of hemorrhagic shock, and
matically from that of an adult. These differences at this stage children are less able to recover
are important to identify in the setting of an and compensate for the hemodynamic changes.
injured child. Therefore, one should have a high index of sus-
picion for hypovolemic shock in the presence
of other supporting symptoms such as tachy-
22.3.1 Anatomic Predisposition cardia, delayed capillary refill, and poor perfu-
to Injuries sion. Normal vital signs vary with the age
group, and therefore a good basic familiarity
Regarding head and brain development, children with what is the normal range for each age
have a greater head-to-body ratio, incomplete group is essential using age-adjusted criteria
brain myelination, and thinner cranial bones (Table 22.1) [4, 8–10].

Table 22.1  Age-adjusted vital signs for pediatric patients [4, 8–10]
Respiratory rate Heart rate Systolic blood Urinary output
Age group (breaths/min) (beats/min) pressure (mm Hg) (mL/kg/h)
Infant: 0–12 months <60 <160 >60 2.0
Toddler: 1–2 years <40 <150 >70 1.5
Preschool: 3–5 years <35 <140 >76 1.0
School age: 6–9 years <30 <140 >80 1.0
Preadolescent/adolescent: 10–18 years <30 <100 >90 0.5
22  Principles of Damage Control for Pediatric Trauma 235

22.3.3 Hypothermia Our understanding of the drivers and mecha-

nism behind ATC in adults is advancing; endothe-
The counterpart to exposure is consideration of lial activation and hyperpermeability leading to
the environment and the potential for hypother- protein C activation, unregulated hyperfibrinolysis,
mia in children. Though smaller in size overall, platelet dysfunction Weibel-Palade body degrada-
infants and children have a proportionately large tion, glycocalyx shedding, and inflammatory medi-
body surface area relative to their weight that pre- ators [23–29] have all been implicated in the adult
disposes them to greater amounts of heat loss and basic science literature. Literature regarding the
resulting hypothermia. Maintenance of normo- pathophysiology of ATC in children is lacking.
thermia is critical in preventing coagulopathy, Children have a distinct hemostatic response to
cardiorespiratory compromise, and unnecessary trauma and injury profile as compared to adults;
increase in metabolic demands [11]. In addition however, the impact of this phenomenon on bleed-
to increased room temperature, additional meth- ing and coagulopathy has not been fully elucidated.
ods such as warmed blankets, head wraps, Hemorrhagic shock is less common, while trau-
warmed humidified oxygen, warmed fluids and matic brain injury is the number one cause of mor-
blood, and radiant heat sources should be utilized bidity and mortality in children [5]. Further, overall
promptly [6]. mortality is much lower [30], and late death after
injury [31] and death due to organ failure or sepsis
is a rarity in pediatric trauma patients [32]. The fac-
22.4 Damage Control tors responsible for the disparate response to injury
Resuscitation are largely unknown. Regarding hemostasis, the
level and activity of clotting factors are incredibly
22.4.1 Acute Traumatic varied across infancy, childhood, and adolescence
Coagulopathy [33]. It is clear that adult “normal” ranges and path-
ways cannot be assumed equivalent in children,
Acute traumatic coagulopathy is a multifactorial and further research is indicated to clarify the etiol-
dysregulation in the hemostatic and inflammatory ogy of ATC in a pediatric cohort.
systems in response to an injury event. While
exogenous contributors to coagulopathy may
potentiate this process, namely, the “vicious triad” 22.4.2 Massive Transfusion
of dilution, acidosis, and hypothermia, ATC is a in Pediatric Trauma
unique entity that encompasses the body’s endog-
enous maladaptive response to injury. ATC as 22.4.2.1 Defining Massive
defined by admission INR ≥ 1.3 is common in Transfusion in Pediatric
critically injured children, with incidence rates Patients
that range from 20% to 40% [12–15]. ATC is clin- Pediatric trauma encompasses the care of injured
ically relevant as it predisposes patients to poor patients aged 0–18+, necessitating weight- and
outcomes. In patients with traumatic brain injury, volume-based definitions of massive transfusion
admission ATC is associated with worse out- to standardize practice. Unfortunately, centers
comes on the Glasgow Outcome Scale, a measure employ diverse definitions of massive transfusion
of functional disability [16–19]. In patients with that may include blood loss of greater than 40 cc/
polytrauma, retrospective studies have found an kg [34, 35], greater than 70 cc/kg [36–38], greater
association between admission coagulopathy and than 50% total blood volume lost in first 24 h [39],
mortality [12, 14, 15, 20, 21]. This association is and greater than 50% total blood volume lost in
even more pronounced in patients with abusive first 3 h or 100% total blood volume lost in first
head trauma [22], a mechanism of injury that is 24 h [40]. Further complicating the development
unique to the pediatric population. of a standardized definition is the fact that total
236 C.M. Leeper et al.

blood volume varies by age: infants less than ratios is lacking. Challenges to answering this
3 months have 90–100 cc/kg, children older than clinical query are twofold: first, both the inci-
3 months have 70–80 cc/kg, and obese children or dence of massive transfusion for hemorrhagic
adult-sized adolescents have 60–65 cc/kg. shock and the outcome of mortality are rare
In a 2015 study, using data from the occurrences in pediatric patients. The vast major-
Afghanistan and Iraq conflicts, Neff et al. ity of studies are inadequately powered to make a
addressed these inconsistencies to propose the conclusion regarding mortality as an outcome
use of 40 cc/kg of all blood products given at any and rely on retrospective data as prospective
time in the first 24 h to define pediatric massive single-­center studies are typically futile given the
transfusion. This definition identified children at rarity of death. Second, most studies do not have
increased risk of both 24-h and in-hospital death an adequate experimental group, as many centers
and distinguished a population that was more report failure to achieve 1:1:1 component ratio
severely injured and more often in shock, hypo- resuscitation in many cases despite the utilization
thermic, and coagulopathic. Using this definition of a massive transfusion protocol. Nosanov et al.
in future research, studies and protocols will reviewed 105 massively transfused trauma
allow for consistent and valid comparisons across patients and concluded that higher plasma/PRBC
cohorts undergoing massive transfusion. and platelet/PRBC ratios were not associated
with increased survival in children. However,
22.4.2.2 Massive Transfusion only 19 died, 34% achieved 1:1 plasma/PRBC
Practices in Pediatric Centers ratio, and 12% achieved 1:1 platelet ratios [39].
A recent survey of pediatric centers reported that All deaths were due to traumatic brain injury.
97% had a massive transfusion protocol in place Chidester compared patients in whom MTP was
for trauma patients [41]. Local definitions for what activated with patients who received uncross-
defined MTP were utilized and not expressly matched packed cells but no formal activation.
stated. All centers utilized trauma surgeon judg- The plasma/PRBC ratio in both groups was 1:3,
ment to trigger MTP (100%), followed by other although the MTP target was 1:1. Mortality was
physician judgment (75%), transfusion of uncross- equivalent between groups, though interestingly,
matched packed red blood cells (56.1%), and DVT incidence was less in non-MTP group [44].
hypotension (56.1%) as the next most common Hendrickson reported a pre-/post-MTP analysis
activation criteria. Out of 131 centers, 57% target that improved plasma/PRBC ratios (1:1.8 post
1:1 plasma to RBC ratio and 87.8% target ≥ 1:2 vs. 1:3.6 pre) but again failed to achieve the target
plasma to RBC ratios with the initial round of of 1:1. There was no difference in mortality [37].
resuscitative products. Regarding platelets, 72.5% Lastly, Edwards described a military cohort of
target 1:1 platelet to RBC ratio and 78.6% tar- injured patients in combat hospitals in the Middle
get  ≥ 1:2 platelet to RBC ratios with the initial East; 1:1 ratio was not associated with improved
round of resuscitative products. Regarding the use survival in massively transfused patients and in
of other adjuncts, 49% incorporate cryoprecipitate fact worsened survival in patients who were
and 50% include antifibrinolytics (TXA or amino- transfused but did not require MTP [36].
caproic acid) in their MTP policies. Prospective, multicenter trials are required to
determine the effect of balanced ratio ­resuscitation
22.4.2.3 C  omponent Blood Therapy in a critically injured pediatric population.
Ratios
Massive transfusion protocols (MTP) have been
shown to decrease morbidity and mortality in 22.4.3 Directed Resuscitation/
adult trauma patients by expediting time to trans- Thromboelastography
fusion and replacing red blood cells, plasma, and
platelets in a fixed ratio (1:1:1) to minimize coag- Many adult centers are incorporating guided
ulopathy, hypothermia, and acidosis [42, 43]. In resuscitation strategies using viscoelastic
pediatric patients, the evidence regarding optimal studies (Fig. 22.1) as an adjunct or replacement
22  Principles of Damage Control for Pediatric Trauma 237

1 Citrated RapidTEG
Sample: 7/23/2015 12:19PM-01:34PM

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sec min min deg mm d/sc % % %
144.0 1.0 5.2 50.4 36.2 2.8K 67.8 *79.3* 67.8
86—118 0—1 1—2 64—80 52—71 5.3K—12.3K 0—8 0—15

Fig. 22.1  Rapid thromboelastograph in a 7-year-old female with arterial laceration who presented in hemor-
rhagic shock. Tracing demonstrates inadequate clotting factors, fibrinogen, and platelets as well as primary
hyperfibrinolysis

for empiric fixed-ratio transfusion. These stud- cause direct cellular damage through the activa-
ies, which include thromboelastography tion of inflammatory mediators [27, 51]. There
(Haemonetics© TEG©) or thromboelastometry is evidence in the adult trauma literature and ani-
(TEM, © TEM Systems Inc.), differ from con- mal studies to suggest that permissive hypoten-
ventional tests of coagulation like prothrombin sion may decrease mortality in adults with
time (PT) and partial thromboplastin time (PTT) hemorrhagic shock [52, 53]. There is no evi-
in that they can provide detailed information dence in the pediatric literature to support or
regarding clot formation, kinetics, strength, and reject this strategy. However, hypotension is a
breakdown in a matter of minutes. Research in late sign of hemorrhagic shock in children and
both adult and pediatric patients demonstrates often portends impending cardiovascular col-
that TEG derangements correlate with conven- lapse. It is typically not well tolerated by pediat-
tional tests, are better predictors of poor outcome ric patients, and therefore this strategy is not
and need for transfusion [20, 45, 46], and can be routinely utilized for pediatric trauma patients.
used to target patient’s specific coagulation defi- Further, hypotension in pediatric patients may
ciencies during a resuscitation [47, 48]. be associated with isolated head injury as opposed
to hemorrhagic shock. Permissive hypotension is
not appropriate in patients with traumatic brain
22.4.4 Permissive Hypotension injury as even a single measure of systolic blood
pressure <90 mmHg in the course of prehospital
Permissive hypotension is a resuscitative strat- and initial hospital resuscitation results in
egy in bleeding trauma patients that calls for increased mortality and disability [54–56]. A
judicious fluid administration while still main- recent study of the National Trauma Databank
taining end-organ perfusion. This approach is revealed that hypotension occurred after isolated
based on the premise that increased hydrostatic head injury in children of all ages and the risk of
pressure and can inhibit or disrupt clot forma- hypotension after head injury is as great as after
tion [49], large volume crystalloid can lead to hemorrhagic injuries in children aged 0–4 years
dilution and hypothermia [50], and fluids may [57]. While hypotension is considered to be
238 C.M. Leeper et al.

s­econdary to hemorrhagic shock until proven

otherwise, the source of hypotension in pediatric
patients is not always clearly defined. This high
proportion of pediatric patients with traumatic
brain injury is also a deterrent to wide adaptation
of this strategy in children.

22.5 D
 amage Control Surgery
for the Pediatric Trauma
Patient

Damage control surgery for the pediatric patient

15 year old patient who sustained liver and bowel injury due
achieves the same goals as in adult patients: early to blunt abdominal trauma. A negative pressure wound dress-
control of surgical bleeding, control of intra-­ ing is in place after damage control procedure (Courtesy:
abdominal contamination, abdominal packing for Children’s Hospital of Pittsburgh of UPMC)
control of coagulopathic bleeding, temporary
abdominal closure and delayed definitive proce-
dures and closure to allow for second-look opera-
tions, resuscitation in the setting of coagulopathy,
hypothermia and acidosis, and avoidance of
abdominal compartment syndrome. As fewer
injured children present in hemorrhagic shock,
the relative infrequency of this strategy in the
pediatric trauma patient precludes large clinical
trials to investigate optimal timing of operations,
various closure devices, resuscitation strategies,
etc. However, there are published case reports
and many anecdotal experiences to demonstrate
the successes of damage control surgery in chil-
dren [58–61]. Fig. 22.2  Grade 4 splenic laceration with a large intrapa-
As in adults, a rapid transfusion device and renchymal hematoma and active extravasation, managed
nonoperatively
cell saver should be available in the event of
massive blood loss. The patient is prepped from
the neck to knees to allow for entrance into either Solid organ injury is common is pediatric
the chest or abdomen and to permit access to the trauma patients. The spleen is the most com-
femoral vessels. Upon entrance to the abdomen, monly injured solid organ (25–39%), followed
the four quadrants are packed to tamponade the by the liver (15–37%), kidney (19–25%), and
bleeding, and the abdomen is then explored in a pancreas (7%) [62]. Management and outcomes
systematic fashion after allowing time for the of the pediatric patient with solid organ injury
anesthesiology team to resuscitate and transfuse differs dramatically from management of the
as needed. Surgical bleeding and fecal contami- adult patient with similar grade of injury. In con-
nation should be addressed expeditiously, and trast to adults, splenic injury and hepatic injury
temporary abdominal closure should performed in children are typically successfully managed
using any number of methods, including nega- nonoperatively in the vast majority of cases even
tive pressure wound dressings, temporary patch with high-grade injuries [63] (Figs. 22.2 and
abdominoplasty, sterile bag closure (Bogota bag, 22.3). Therefore, a trial of resuscitation and
bowel bag, Steri-Drape, or silo), and skin-only observation is indicated for most solid organ
closure (Fig. 22.1). abdominal injuries. Failure of nonoperative
22  Principles of Damage Control for Pediatric Trauma 239

particularly those with high-grade injuries or evi-

dence of splenic vascular injury.
Overwhelming postsplenectomy infection
(OPSI) is a rare consequence of splenectomy
with an incidence of 0.23% per year that is
increased in children less than 2 years of age.
Vaccinations against encapsulated bacteria,
including pneumococcus, Haemophilus influen-
zae type B, and meningococcus, should be
administered after splenectomy [69]. Children
who receive antibiotic prophylaxis have a
decreased incidence of OPSI; therefore, it is rec-
ommended for all pediatric patients after sple-
nectomy for trauma. Oral penicillin V twice
Fig. 22.3  Grade 4 liver laceration with large subcapsular
daily or amoxicillin is first-line therapy, with
hematoma, managed nonoperatively erythromycin or Bactrim as alternates for
patients with penicillin allergy. The duration of
antibiotic prophylaxis is controversial and evi-
management in patients attempting conservative dence-based guidelines are lacking. Most
management is signified by worsening abdomi- experts recommend that prophylaxis be contin-
nal exam, ongoing transfusion requirements, and ued until age 5 or, for patients who become
hemodynamic instability (particularly hypoten- asplenic after age 5, for at least 1–2-year dura-
sion) [64]. Immediate operative intervention is tion. For high-risk patients, prophylaxis is typi-
indicated in patients with hemodynamic instabil- cally continued into adulthood. Long-term use
ity, peritonitis or suspected hollow viscus injury, of antibiotics carries the increased risk of anti-
and major pancreatic ductal disruption. microbial resistance; therefore, the decision to
continue antibiotics should be based on the clin-
ical circumstances of each individual patient
22.5.1 Splenic Injury [70–72].

Splenectomy easily controls bleeding from a

massively injured spleen and is indicated in the 22.5.2 Liver Injury
hemodynamically unstable patient. Children with
splenic injuries who have ongoing bleeding, but A major hepatic injury is more difficult to con-
are not in shock, are potential candidates for trol in the operating room; high-grade injury,
splenic sparing operations such as partial sple- hepatic vascular injury, and the need for opera-
nectomy and mesh splenorrhaphy; however, tive intervention are associated with high rates of
these techniques can be time-consuming and are mortality in both adult and pediatric patients
not appropriate in the setting of hemorrhagic [73]. The likelihood of successful intervention is
shock [7]. The use of splenic artery embolization increased with adequate operative exposure, an
has increased the success of nonoperative man- experienced co-surgeon, good anesthesia sup-
agement in the adult population, while the role of port, and supradiaphragmatic intravenous access.
interventional radiology is less clear in the pedi- Operative technique may include parenchymal
atric population where splenic preservation is compression, the use of the Pringle maneuver
already the rule rather than the exception. with intermittent clamping of the porta hepatis,
However, limited data suggests that splenic artery suture ligation of bleeding vessels, and the avoid-
embolization is feasible and safe, may increase ance of deep liver sutures [74].
the rate of splenic salvage in children [65–67], Goals of the definitive operation are to ensure
and results in preserved splenic function [68], adequate hemostasis, control bile leak, debride
240 C.M. Leeper et al.

nonviable tissue, and adequately drain the (proximal vs. distal) are the major factors guid-
resection bed. Large parenchymal fractures are ing management decisions. For main pancreatic
best treated with anatomic or nonanatomic ductal injury (Grades 3–5), resection is the pre-
resection, assuming sufficient residual liver ferred approach with distal pancreatectomy for
remains [7]. Resection can be efficiently per- most distal duct injuries and conservative inter-
formed using mechanical staplers. Adjuvant ventions (closed suction drainage and endo-
interventions may include interventional radiol- scopic stenting) for proximal ductal injuries
ogy procedures such as angioembolization or involving the head of the pancreas [78].
endoscopic retrograde cholangiopancreatogra- Preservation of the spleen, particularly in pediat-
phy with stenting. These procedures are ric patients, should be prioritized if possible.
­performed less commonly in pediatric popula- Radical procedures such as pancreaticoduode-
tions [75]; however, the experience of multiple nectomy or the creation of pancreatic-enteric
high-volume trauma centers over the past anastomoses are not widely recommended.
decades demonstrates both feasibility and
safety in children and suggests diagnostic and
therapeutic benefits when utilized in ­appropriate 22.5.4 Hollow Viscus Injury
pediatric patients [65, 66, 76]. These patients
may include those with evidence of ongoing Hollow viscus injuries in pediatric patients are
bleeding and hemodynamic stability and those typically the result of a direct blow to the abdo-
with concern for ongoing bleeding after damage men, a deceleration mechanism (e.g., belted
control p­rocedure or later in their hospital patient in MVC), handlebar injury, or associ-
course. Follow-up imaging for patients with ated lumbar spine injury [79] and involve the
high-grade injury may be warranted and should jejunum, duodenum, colon, and stomach in
be pursued based on clinical presentation and decreasing order of frequency [62]. The diagno-
postoperative condition. sis of intestinal injury can be challenging as
imaging is less sensitive than for solid organ
injuries and a patient’s symptoms may be mild,
22.5.3 Kidney and Pancreas Injury delayed, and nonspecific. Clinicians should
have a high index of suspicion in patients with
Operative intervention for kidney injury is indi- tachycardia, abdominal wall bruising, or seat
cated in patients with hemodynamic instability, belt sign [80, 81]. Symptoms may include
expanding retroperitoneal hematoma, vascular abdominal pain, peritonitis, and bilious emesis.
pedicle injury, or other major renal vascular Radiologic indicators may include free fluid,
injury [77]. In an initial damage control opera- but often imaging is normal. Laboratory find-
tion, nephrectomy can be performed for massive ings may include elevated lipase, white blood
parenchymal destruction and ongoing bleeding, cell count, or lactate.
and the ureter may be ligated with plans for future Immediate operative intervention is indicated
urinary reconstruction once the patient has in patients with hemodynamic instability, perito-
stabilized. nitis, or in patients with a high degree of suspi-
Pancreatic injury is uncommon in children cion for injury based on the presence of above
and typically does not require surgical interven- factors. The injuries resulting from hollow viscus
tion at the initial damage control surgery. trauma can include frank bowel perforation or
Regarding the definitive operation, optimal man- tearing, bowel wall hematoma, and mesenteric
agement is controversial and frequently debated tears that may devascularize bowel and result in
among experts. For both penetrating and blunt ischemia or necrosis. The first priority of the
pancreatic injuries, the presence of main pancre- damage control procedure is control of intestinal
atic ductal injury and the location of injury content spillage and removal of devitalized tissue
22  Principles of Damage Control for Pediatric Trauma 241

with delayed restoration of bowel continuity or symptoms or other concurrent injuries of abuse,
diversion at subsequent operations when the and CT abdomen/pelvis if signs of abdominal
patient is hemodynamically stable. trauma or elevated transaminases. Consultation
to ophthalmology for a dilated eye exam, neuro-
surgery for intracranial hemorrhage and neurol-
22.5.5 Child Abuse ogy for seizures may be indicated. Social work
involvement with notification of the appropriate
Abusive head trauma (AHT) is an injury mecha- authorities and plans for safety at discharge are
nism unique to the pediatric population that pref- imperative.
erentially affects the youngest and most Damage control procedures in victims of
vulnerable patients. The incidence of AHT is child abuse follow the same principles of dam-
estimated to be 20–30 cases per 100,000 children age control surgery in accidental trauma
[49] with a case fatality rate that ranges from patients. One consideration that complicates
15% to 35%. Presentation to care for abused diagnosis and management of these patients is
patients peaks around 2–3 months of age, and the that clinical presentation of injuries may be
majority of children are 2 years of age or younger unusual. For instance, a patient with massive
[49, 56]. Challenges in caring for this cohort abdominal hemorrhage requiring immediate
include frequent delays in diagnosis as young laparotomy may present with cardiac arrest of
patients cannot report their abuse history and unknown etiology, chief complaint of “found
guardians may not be forthcoming about or aware down,” “fussy” “irritable” or nonspecific nau-
of the abuse [57–59], as well as the fact that sea, vomiting, or mental status changes.
patients likely have suffered multiple discrete Maintaining a high index of suspicion will
events over a period spanning days to months facilitate early intervention and appropriate
[60] and identification of “time of injury” may be resuscitative and operative strategies to address
impossible. the severe injuries that a badly abused child has
The abusive head injury population differs sustained. Another note for the trauma surgeon
clinically from the accidental head injury popula- is the importance of recognizing injuries con-
tion in that they have higher mortality rates [49– sistent with the history versus those consistent
51] and worse neurologic outcomes that persist with a diagnosis of child abuse (e.g., a patient
decades after injury [49, 52–55]. The reasons for found to have duodenal transection where the
this are multifactorial; from a mechanistic stand- history is a fall from 4 ft while playing). Unless
point, evidence suggests that the pathophysiol- a patient has a mechanism to support the injury
ogy of brain damage in abusive head trauma does (motor vehicle collision deceleration injury),
not result from a direct traumatic mechanism, but this is diagnostic of child abuse and should be
instead from a hypoxic-ischemic insult that stated unequivocally as such.
occurs after trauma-induced apnea [61–64].
Hyperextension injury to the neck due to violent
shaking has been implicated in damaging the 22.6 D
 amage Control Principles
central pattern generator of respiration in the in Pediatric General Surgery
brainstem [61].
Evaluation of patients with suspected child 22.6.1 Abdominal Compartment
abuse should start with a thorough medical his- Syndrome (ACS)
tory and physical exam with careful photo-
graphic and written documentation of all Intra-abdominal hypertension is defined as an
findings. Patients with high suspicion of abuse intra-abdominal pressure (IAP) greater than or
should also have a complete skeletal survey, equal to 12 mmHg, while ACS is defined as an
head CT if facial/scalp bruising, neurologic IAP above 20 mmHg with the development of
242 C.M. Leeper et al.

new or worsening organ dysfunction/failure the abdominal wall defect. Historically, imme-
[82, 83]. It is often diagnosed in a delayed fash- diate primary repair was routine practice as
ion in pediatric patients perhaps due to lack of patients did not survive without closure.
familiarity or recognition of this phenomenon Schuster first described the use of prosthetic
and is associated with high mortality rates material for temporary closure in infants in
between 40% and 60% in children [84–86]. 1967 [1]. In patients at risk of developing
While the most common cause of ACS in chil- abdominal compartment syndrome, the use of a
dren is abdominal trauma with hemorrhage or silo allowed for gradual intestinal reductions
visceral edema, other causes include intraperi- through serial procedures either in the operat-
toneal sepsis, massive fluid resuscitation, mas- ing room or at the bedside, followed by delayed
sive ascites, rapid tumor growth as in stage abdominal wall closure (Fig. 22.3). Patients
IV-S neuroblastoma, and severe constipation who undergo silo placement as compared to
[87, 88]. primary repair have similar complications and
ACS can be diagnosed and monitored using mortality but longer hospital stays and costs.
bladder pressure measurements. Initial medical About 50% of patients with gastroschisis will
management includes adequate sedation and develop subsequent ventral hernia that may
paralysis, evacuation of intralumenal intestinal require later repair [90–92]. Sutureless closure
contents, evacuation of large abdominal fluid of the abdominal wall defect with negative
collections, optimization of fluid administration pressure dressing has also been utilized in many
by goal-directed therapies, and correcting posi- institutions and can be performed at the bedside
tive fluid balance. Surgical management [93] (Fig. 22.3).
includes decompressive laparotomy with the
goals of decreasing the elevated IAP to stop
organ dysfunction, allowing room for expan-
sion of the viscera during ongoing resuscita-
tion, providing temporary abdominal viscera
coverage, preventing excessive fascial retrac-
tion, and allowing a means for continued evacu-
ation of fluid from the peritoneal cavity [7, 89].
Coverage can be achieved through multiple
methods including application of a negative
pressure wound dressing (e.g., vac-pac), tempo-
rary patch abdominoplasty, or silo. Staged
abdominal closure is performed when ACS has
resolved.

22.6.2 Abdominal Wall Defects:

Gastroschisis

Gastroschisis is a congenital abdominal wall

defect in which the intestines fail to assume
their position in the peritoneal cavity in utero
and develop outside the abdomen. Postnatal
management requires early coverage of abdom-
inal contents followed by definitive closure of
22  Principles of Damage Control for Pediatric Trauma 243

This strategy allows for abdominal decompres-

sion as well as periodic evaluation of bowel
viability in cases where the initial operation
revealed marginal segments of the intestine or
concern for ongoing ischemia.

22.6.4 Congential Diaphragmatic

22.6.3 NEC Hernia

Necrotizing enterocolitis (NEC) is a multifacto- Temporary abdominal closure is also useful in

rial disease that leads to disruption of intestinal the reduction and repair of a large congenital
integrity followed ultimately by bowel necrosis ­diaphragmatic hernia (CDH). The most com-
and bacterial translocation. Birth weight is mon type of CDH is a Bochdalek hernia, or
inversely associated with incidence (1:1,000) defect in the posterolateral diaphragm, the
and mortality (15–30%). Younger gestational majority of which occur on the left side. Clinical
age is also a predictor of poor outcome. The presentation includes respiratory distress in a
clinical presentation of NEC includes feeding newborn caused by pulmonary hypoplasia and
intolerance, abdominal distention, and often pulmonary hypertension. Radiographic find-
bloody stool [94]. Pneumatosis intestinalis is ings demonstrate passage of abdominal con-
the hallmark radiographic finding, and operative tents into the chest cavity. Reduction of these
indications include worsening hemodynamics contents into the abdomen during operative
or physical exam, free intraperitoneal air, or repair can result in intra-­abdominal hyperten-
clinical concern for bowel necrosis. Initial sion. Further, a recent study noted a reduction
abdominal exploration accomplishes removal of in cerebral blood flow in infants who underwent
devitalized intestine and diversion versus pri- repair of a large CDH with primary abdominal
mary anastomosis depending on bowel charac- closure [95]. The use of TAC devices has been
ter and a patient’s clinical status. Fascial closure shown to be feasible and effective in reducing
may be accomplished at that time; however, both IAH and the resultant decrease in cardiac
TAC may be indicated in some populations. output [88, 96–98].
244 C.M. Leeper et al.

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 Principles of Damage Control
in the Elderly
23
Pol Maria Rommens and Sebastian Kuhn

23.1 Introduction “dangerous” activities such as being pedestrian

within dense traffic, using motor vehicles or
Demographic development in high-income motorcycles, hiking and climbing, or working at
countries leads to an absolute and relative a height (e.g., on a ladder). All this leads to an
increase of elderly people. Whereas the longev- increasing part of elderly persons among poly-
ity has steadily grown, birth rate decreases to a traumatized patients. Broos et al. calculated in
value below the population replacement rate. In 1988 a percentage of 12% of persons above the
The World FactBook 2011, Germany ranks sec- age of 65 years (n = 49) among 416 multiple
ond in the statistics of median age of the coun- injured patients [3]. More than three decades
try’s population. Only Japan has an older later, the percentage of polytraumatized patients
population with a median age of population of of 65 and older has risen up to 30% in the USA
46.7 years. Germany has a median age of [4]. The German TraumaRegister DGU® docu-
46.0 years. On the places three to six rank ments an increase in the average patient age
Canada, Great Britain, Poland and the USA from 39.0 years in 1999 to 50.9 years in 2014.
with mean ages of their population of 42.1, Currently patients of ≥60 years of age account
41.1, 40.3 and 38.2 years respectively [1]. In for 37% of all polytraumatized patients [5].
comparison with 2016, the total population of Whereas the percentage of severely injured
the EU will have decreased with 5% in 2050, patients in adolescents and young adults is
whereas the rate of persons above 60 years will strongly in favor of males and the percentage of
have increased with 40% [2]. low-energy trauma in elderly is strongly in favor
Among the elderly population, many are of females, the incidence of severely injured in
healthy, mobile, and sportive and have high the elderly is equal among females and males
demands on quality of life and mobility. Conduct [6]. Blunt trauma mechanisms account for
of an active lifestyle leads to participation in almost all injuries in the multiple injured older
persons [7]. Motor vehicle accidents and falls
from height as well as pedestrians being hit by a
P.M. Rommens (*) • S. Kuhn motor vehicle are the most frequent causes of
Department of Orthopedics and Traumatology, trauma [8, 9].
University Medical Center, Johannes There is a rapidly increasing interest in the
Gutenberg-University, Langenbeckstrasse 1, older polytraumatized patient. In recent litera-
55131 Mainz, Germany
e-mail: pol.rommens@unimedizin-mainz.de; ture, these patients have been identified as a spe-
Sebastian_kuhn@me.com cific group of trauma patients, which require

© Springer International Publishing AG 2017 249

H.-C. Pape et al. (eds.), Damage Control Management in the Polytrauma Patient,
DOI 10.1007/978-3-319-52429-0_23
250 P.M. Rommens and S. Kuhn

special attention and adapted treatment proto- respond to resuscitation [14]. An increasing num-
cols. In the large majority of these recent papers, ber of elderly persons receive anticoagulants for
elderly persons are classified as being 65 years prophylactic (e.g., atrial fibrillation, after vascular
and older. stent implantation) or therapeutic (after thrombo-
embolism) reasons. These drugs, especially cou-
madin, phenprocoumon, low-molecular-weight
23.2 Age-Related Physiologic heparin, and factor X blockers, may prolong dura-
Alterations in Adults tion and volume of blood loss after trauma [15].
Oral anticoagulant drug therapy should be inter-
Aging is characterized by a continuous decline in rupted and replaced by low molecular or unfrag-
physiological reserves. Moreover, aging is con- mented heparins given as a “bridge treatment.”
nected with the appearance of diseases. In a Chronic obstructive pulmonary disease
recent US study on 32,440 patients of 55 years of (COPD) is a common disease of the elderly and
age and older, who suffered hip fractures, more is often connected with congestive heart failure.
than 95% had at least one comorbidity. COPD leads to a reduced vital capacity and pul-
Hypertension, deficiency anemia, and electrolyte monary function, which increases the risk of pul-
disorders were the most common [10]. Loss of monary complications during and after surgery
physiological reserves and comorbidities in the [16]. Steroids, which are given for COPD may
elderly are both considered as independently alter the physiological response to trauma,
influencing factors in regard to morbidity and including a reduced immunologic reaction and
mortality after trauma [11]. delayed wound healing.
The most important declines of organ function Anemia is frequently detected in the elderly.
concern the heart, lungs, kidneys, liver, and bone. The blood transfusion regimen after severe geri-
A reduced cardiac output and a low physiologic atric trauma should therefore not be too aggres-
reserve of the lungs limit the ability to respond to sive, with hemoglobin values of 10 or lower
hemodynamic instability due to blood loss. As a generally being acceptable as endpoint of resus-
result of reduced functions of kidneys and liver, citation [17].
clearance of metabolic and toxic agents and drugs Also diabetes is often diagnosed in persons
is delayed or hindered. Bone mineral density is older than 65. This disease is responsible for an
reduced in elderly persons. A similar trauma mech- important number of consecutive complications
anism may lead to more and more complex injuries such as peripheral microangiopathy, peripheral
than in the younger adult. These factors negatively neuropathy, heart and renal failure, retinopathy
influence morbidity and mortality [12, 13]. with reduced eyesight, and wound healing distur-
One or several comorbidities are present in the bances. Glucose levels should be kept in normal
vast majority of the elderly. Hypertension and ranges throughout the whole length of intensive
heart disease are very common. There is a reduced care and in-hospital stay [18, 19].
ability to respond to hypovolemia and shock.
Younger adults react to hypovolemia with central-
ization of intravascular volume leading to 23.3 M
 echanisms and Patterns
increased heart rate and temporary increased of Injury
blood pressure. The elderly are not able to develop
the same response. Moreover, this physiological Low-energy injuries, especially domestic falls,
response may be hindered due to medications, remain the predominant cause for fractures in the
especially beta blockers and steroids, which are elderly. The risk of suffering a fracture after a fall
often prescribed in the elderly. A normal heart rate steadily increases with age. Comorbidities such
or a normal blood pressure may therefore give the as cardiac arrhythmia, decreased vision, periph-
false impression of the patient being less severely eral neuropathy, and a longer reaction time make
injured than he/she really is or appearing to the elderly more prone to a fall. Decreased bone
23  Principles of Damage Control in the Elderly 251

mineral density due to osteoporosis is another with a higher mortality. In an older Swedish retro-
factor which dramatically enhances the risk of spective study over a 30-year period, mortality
suffering a fracture after a fall [20]. after abdominal trauma in patients older than
Blunt trauma is also the leading cause of high-­ 60 years was 27.6%, whereas mortality in the
energy injuries in the elderly. Motor vehicle acci- younger patient population was 9.1% [27]. In a
dents, either as the driver or as a pedestrian hit by more recent retrospective study performed over a
a car and falls from height, are the number one 6-year period on 90 patients with age over
and two mechanisms of polytrauma [8, 9]. 55 years, mortality after trauma laparotomy was
Different studies show high percentages of trau- 23.3% and progressively increased with age [28].
matic brain injury and of musculoskeletal inju-
ries, whereas thoracic and abdominal injuries are
less common [9, 21]. In a retrospective analysis of 23.4 P
 rinciples of Management
the National Trauma Data Bank of USA (2002– of the Polytraumatized
2006), Siram et al. found that elderly patients Elderly
(above 75 years of age) had significantly higher
rates of pelvic, upper, and lower extremity frac- 23.4.1 Triage
tures as well as intracranial injuries than younger
adults [22]. Sullivan et al. performed an epidemi- The principles of advanced trauma life support
ologic study using data from 1993 to 2010 of the (ATLS) should also apply for the elderly. Airway,
Nationwide Inpatient Sample (NIS) looking at breathing, and circulation have the highest priority
more than 600 million Medicare-paid hospital in posttraumatic resuscitation. Life comes before
discharges of patients above the age of 65. limb. The main challenge of the prehospital phase
Whereas traditional hip fractures declined by is the correct estimation of the severity of the inju-
25.7%, geriatric acetabular fractures increased by ries and their impact on the physiologic status of
67% and pelvic fractures by 24% [23]. Although the patient. Underestimation is a common prob-
most of the NIS patients suffered a low-energy lem and has different reasons: inadequate training,
trauma, this data supports our observation that the unfamiliarity with protocol, and age bias [29]. In a
incidence of pelvic and acetabular fractures is rap- retrospective study performed at the Maryland
idly increasing in the old patient population. In a Ambulance Information System over a 10-year
retrospective Canadian study on 276 multiple period, under triage rate was significantly higher
injured patients of age 65 and older between 2004 in patients aged 65 years or older: 49.9% versus
and 2006, spine injuries were present in 17% [7]. 17.8%. As stated above, the response to trauma is
The type of treatment of spine injuries is relevant reduced in elderly victims due to a limited physi-
for outcome. In a retrospective study on 154 ologic reserve, comorbidities, and medication.
severely injured patients with a mean age of This may lead to the false impression that the “first
76 years and an ISS of 23, nonoperative treatment hit” was not that severe. Underestimation leads to
of spine injuries was associated with a higher undertreatment, which enhances the risk of mor-
mortality [24]. Due to the high incidence of osteo- tality. Emergency medical service providers and
porosis, blunt chest trauma in the elderly is com- emergency physicians, who are not really familiar
monly combined with rib fractures. There is a with treatment protocols of elderly trauma vic-
higher mortality than in younger adults and chil- tims, transported their patients to non- or low level
dren [25]. With the number of rib fractures, mor- trauma centers, where adequate treatment was not
tality and morbidity (number of ventilator days, initiated or delayed. A third problem may be age
number of intensive care unit (ICU) days, pneu- bias. Some care providers may feel that it is not
monia) increase significantly [26]. Abdominal worthwhile starting aggressive resuscitation in the
trauma is less frequent than traumatic brain injury severely injured elderly, as the chances for a good
or musculoskeletal injuries. It is usually associ- ­outcome are regarded as bad or non-existing [29].
ated with motor vehicle accidents and associated A retrospective cohort study conducted in Ohio,
252 P.M. Rommens and S. Kuhn

USA, on 455 trauma patients of 80 years and ing and/or traumatic brain injury. Alternatively, a
above showed that patients, who were sent directly concentrate-based goal-directed strategy has
to a trauma center, had significant better outcomes proven to be effective. An early use of prothrom-
than those directed to an acute care hospital [30]. bin complex concentrate is recommended for the
Other publications suggest that existing triage emergency reversal of vitamin K-dependent oral
protocols are inadequate for assessing the severity anticoagulants [17]. Coagulation monitoring to
of injury in the elderly trauma patient [31–33]. measure coagulation treatment should be imple-
When age and comorbidities are integrated in the mented as early as possible and used to guide fur-
decision on where to transport the patient, the rate ther hemostatic therapy. Monitoring should
of under triage is considerably diminished [34]. include rotary thromboelastomer [14, 17].
The statement bring the right patient at the right Base deficit with values of −6 mmol/L or
time to the right hospital is more valid than ever lower has been shown to be a sign of severe
for elderly trauma patients. In doubt, such a patient injury and enhanced mortality in all, but espe-
should be transported to a trauma center. cially in elderly patients [42]. Base deficit and
serum lactate are markers for peripheral tissue
perfusion and oxygenation. Consequently, high
23.4.2 Resuscitation at Admission base deficit (−6 mmol/L of lower) and high
serum lactate levels are specific for bad periph-
In-hospital treatment should be guided under the eral perfusion and low oxygen consumption. In a
goal not to harm the patient. Too aggressive retrospective cohort study, Callaway et al. looked
resuscitation or prolonged and extensive surger- at the relation between lactate levels and in-­
ies may bring the patient more harm than benefit hospital mortality in blunt trauma elderly
[35]. Even though the “second hit” may not be patients. There was a 4.2 increased odd ratio of
excluded completely, it should be minimized as dead in patients with a severely increased lactate
much as possible. A basic rule is to avoid the level. There was a 4.1 increased odds ratio of
lethal triad of hypothermia, coagulopathy, and dead in patients with a markedly increased base
acidosis [36]. deficit [43]. This data clearly supports early and
Hypothermia, as frequently observed during continuous invasive monitoring and intensive
primary survey and initial resuscitation, has been care therapy in this group of patients. Scalea
recognized as an independent factor, which et al. showed already in 1990 that “emergent”
increases morbidity and mortality after severe invasive monitoring could reduce mortality in
trauma [37]. Hypothermia reduces cellular activ- severely injured elderly patients from 95% to
ity and metabolism, such as the activity of the fac- 47% [44]. This was confirmed by the data of
tors of the coagulation pathway [38]. Noninvasive Demetriades et al. who performed a comparative
and invasive measures to warm-up the patient study on 336 patients of age 70 years or more.
must be used as soon as possible in the emergency Mortality with early invasive monitoring could
room to prevent or treat hypothermia: higher be reduced from 53.8% to 34.2% [45].
room temperature, thermal blanket, and warmed-
up intravenous infusions [39]. Already at the
stage of pre-ICU resuscitation, massive hemor- 23.4.3 Primary Operative Phase
rhage protocols should be started to compensate
blood loss. It is recommended to combine packed In this early operative phase, the surgeon should
red blood cells (RPBC) with fresh frozen plasma be guided by two directives: treat first what kills
in a 1:1–1:2 ratio for simultaneous treatment of first and do not harm.
blood loss and coagulopathy [40, 41]. Platelets Most patients with a pneumo- and hemotho-
should be administered to maintain a platelet rax after blunt thoracic trauma are successfully
count above 50 × 109/l in all trauma patients and treated with a chest tube [25, 26]. Besides aim-
above 100 × 109/l in patients with ongoing bleed- ing for a better oxygenation, inserting a chest
23  Principles of Damage Control in the Elderly 253

tube is part of the monitoring of ongoing blood instability with signs of hemodynamic instability,
loss or air leakage, which may enforce thora- pelvic binders should already be applied at the
cotomy in a small minority of patients. There site of accident prior to transport to a trauma cen-
must be a high index of suspicion in patients ter. At the latest, they should be applied in the
with multiple rib fractures. In a retrospective emergency room [50]. The benefit of the binder
cohort study on 171 patients, one third of has been proven in several studies [50, 51]. To
patients older than 45 years of age with more avoid pressure sores, the binder should not be
than four broken ribs had pulmonary contu- retained for longer than a few hours. Especially
sions and half had hemopneumothorax. This elderly patients with a frail and damaged soft tis-
population suffered a higher morbidity (ventila- sue envelope are at high risk of developing pres-
tor days and hospital length of stay) than their sure sores or open wounds. Pelvic clamping and
younger counterparts [26, 46]. external fixation both restore stability of the bro-
Damage control laparotomy is useful, also in ken pelvic ring and reduce blood loss [52, 53]. In
elderly patients. In a retrospective study per- elderly, special attention should be paid prevent-
formed at a level I trauma center, more than half ing penetration of the screws through the weaker
of the patients of 55 years of age or older sur- bony structures. We therefore prefer the use of the
vived, despite higher mortality than in younger supra-acetabular external fixator [54]. In case of
patients [47]. The main goals are to stop bleeding combination of pelvic with abdominal trauma,
and to interrupt contamination. The surgery is which necessitates laparotomy, it is of utmost
abbreviated; long surgery is avoided. Complete importance applying the external fixator first.
and definitive repair of the injuries is postponed Laparotomy in patients with unstable pelvic
to later operative phases, when physiologic dis- trauma without previous external fixation is con-
turbances (lethal triad) have been corrected by nected with very high mortality [55]. The external
intensive care therapy. Life-threatening injuries fixator can be left in place for definitive treatment
such as liver bleeding or splenic rupture are of anterior pelvic ring instabilities. With meticu-
treated by liver packing and splenectomy. lous care of the pin tracks, infection rate is low
Ruptured or ischemic bowel is treated with par- [52]. If present, posterior pelvic ring instability
tial resection without anastomosis. The abdomen must be fixed in a second, scheduled surgery.
is left open, which avoids intra-abdominal com- Pelvic packing is a damage control procedure,
partment syndrome, shortens operation time, and which is only used in patients, who do not
enforces second-look surgery [48]. respond well to external compression despite
Musculoskeletal injuries are the most frequent aggressive resuscitation. Overall mortality is as
lesions in elderly severely injured persons. Not high as 28% in adults [56]; survival of elderly
all fractures have to be stabilized in emergency. patients after pelvic packing is not known but
The main goals of emergent treatment of frac- may be lower than in younger adults.
tures are to control major instability, stop con- Angiography and selective embolization is a
tamination, and reduce pain. The techniques used well-known and effective damage control proce-
should be less aggressive, limited in time con- dure for intrapelvic arterial bleeding. Technical
sumption, and ensure high enough stability for success ratio is published to be near 100%, clini-
easy nursing in an intensive care unit. cal efficacy 85% [57]. The challenge is identify-
High-energy pelvic trauma requiring surgical ing the patients with arterial bleeding and
treatment belongs to these skeletal injuries and is adequate timing of the intervention. Patients
associated with high mortality rates in elderly with a high pelvic AIS and a low base excess
patients [24, 49]. Osteo-ligamentar instability level on admission as well as patients with a
leads to life-threatening hemodynamic instability blood transfusion need of more than 0.5 units/h
due to blood loss in the small pelvis. Several pro- were found to be at high risk of active arterial
visional measures can be taken to reduce pelvic bleeding [58]. When an emergency total body
ring instability. In patients with suspected pelvic CT scan with contrast, ideally including an
254 P.M. Rommens and S. Kuhn

a­rterial phase, is performed very early after as a resuscitation tool [60–62]. Prerequisite is a
admission, presence and location of intrapelvic thorough knowledge of sacral anatomy and
arterial blush can be detected. These patients are experience with iliosacral screw osteosynthesis
transferred to the angiography suite immediately in a nonemergency setting (Fig. 23.1a–e). Due to
thereafter and angiography with embolization the emergency environment, the chance of screw
performed subsequently. The procedure can be malpositioning is higher; a replacement of the
started within 1 h after admission [59]. Some screw(s) during second-look surgery may be
authors favor using “antishock” iliosacral screws necessary [61].

a b

c d

e
23  Principles of Damage Control in the Elderly 255

Skeletal injuries of the lower extremity also [63]. Dislocations and fracture dislocations at
ask for urgent stabilization. Proximal fractures the knee joint as well as fractures of the lower
near to the trunk have higher priority than distal leg can easily be stabilized with a (joint-bridg-
lesions. Proximal femur fractures and femoral ing) external fixator. The procedure creates sta-
shaft fractures are connected with high instabil- bility and allows soft tissues to recover from
ity, important blood loss, heavy pain, and diffi- trauma. Open fractures, which are most fre-
cult nursing. Depending on the localization in quent at the lower leg, should be treated in
the proximal femur (intracapsular, intertrochan- emergency with soft tissue debridement, open
teric, subtrochanteric), hip arthroplasty or hip wound care, or vacuum-­ assisted closure if
preserving surgery will be performed. The sur- appropriate and external fixation. External fixa-
gery should be done as soon as possible and be tion will not be the definitive treatment. Mostly,
the definitive solution (Fig. 23.2a–i). Also fem- the fixator will be removed and intramedullary
oral shaft fractures need urgent stabilization. nailing for shaft fractures, open reduction, and
The type of treatment should be less invasive internal fixation for (juxta) articular fractures
and operation time short. External fixation is performed.
the first choice; minimal invasive plate osteo- At the upper extremity, operative stabilization
synthesis (MIPO) and intramedullary nailing is rarely needed in emergency. Only open frac-
are less attractive alternatives. The choice of tures, contaminated wounds, and fracture dislo-
primary treatment must depend on the physio- cations need surgical revision resp. reduction and
logic condition of the patient before surgery. stabilization. Reduction of septic load, preven-
Borderline patients profit more from external tion of secondary damage, and optimization of
fixation than from nailing as primary procedure nursing at the intensive care unit are the main

Fig. 23.1 (a–e) This 84-year-old female pedestrian is hit external fi

­ xator, packing of the small pelvis, plate osteo-
by a car. She suffered a severe polytrauma but could be synthesis of pubic symphysis, and anterior pelvic ring
rescued very early after accident. At the site of accident, injury and bilateral “antishock” iliosacral screws (d).
her initial vital signs were the following: (A) Unprotected During the ER and primary surgical phase, the patient
and obstructed airway. (B) Insufficient breathing efforts received 18 PRBC, 12 FFPs, and 4 TC. The patient sur-
with no SpO2 reading. (C) Pulse 40/min, RRsys 50 mm Hg. vived the primary operation phase and was admitted in the
(D) GCS 3, pupils dilated with little response to light. (E) intensive care unit for further hemodynamic situation and
Multiple contusions. The pre-hospital treatment of the improvement of physiologic situation. Secondary surgical
emergency physician included intubation, volume ther- treatment included depacking of the small pelvis and
apy, vasopressors, and mechanical resuscitation. The osteosynthesis of the clavicle on day 2. Revision of the
patient arrived in the emergency room in severe shock left-sided iliosacral screws on day 20 (e). The patient was
under continued medical and intermittent mechanical discharged after 22 days to an intensive care nursing facil-
resuscitation. Initial base excess was −21.3 mmol/l, ity. However, her Glasgow Outcome Scale (GOS) at dis-
hemoglobin 2.3 g/dl, and core body temperature charge was 2 points, equivalent to a vegetative state. (a)
33.6 °C. After initial radiographic examination, the patient Axial CT cut through the upper thorax showing bilateral
was diagnosed with the following injuries: bilateral unsta- lung contusions and left-sided chest tube. (b) 3D recon-
ble thorax (AIS 5) with bilateral hemopneumothorax struction of the pelvic ring calculated from the total-body
(AIS 4) (a). Fracture of the left clavicle and scapula CT taken during the resuscitation phase. It shows a dis-
(AIS 2). Splenic lesion, grade 2 (AIS 2). Fractures of the ruption of the pubic symphysis with severe displacement
transverse process of the 1st, 3rd, and 5th lumbar vertebra and a left-sided superior and inferior pubic rami fracture.
(AIS 2). Vertically unstable AO-type C3 pelvic ring injury There is a widening of the left iliosacral joint. (c) Axial
(right-sided sacral transforaminal fracture, left-sided ilio- CT cut through the level of S1, showing a sacral transfo-
sacral dislocation, pubic symphysis rupture, and left-sided raminal fracture on the right and an iliosacral dislocation
pubic bone fracture) (AIS 5) (b, c). Ankle fracture, type on the left. (d) Scout of total-body CT taken after the pri-
Weber B (AIS 2). The calculated ISS was 54, NISS 66, mary operative procedure. It shows an anterior pelvic
TASH 22 points (77% risk for mass transfusion), and a external fixator, a symphyseal plate and two iliosacral
RISC II prognostic survival score of 0.5%. Emergency screws in S1 bilaterally. (e) Pelvic a.p. overview taken
surgical procedure included insertion of chest tubes left after the second operative procedure shows the new posi-
and right (pre-CT). Application of a supra-acetabular tion of the left-sided iliosacral screws
256 P.M. Rommens and S. Kuhn

a b

Fig. 23.2 (a–i) This 79-year-old female suffered a fall a­ ngiography and, in case of an active arterial bleeding in
from 5 to 6 m height. Initial assessment at the site of acci- the small pelvis, to embolize the bleeding artery.
dent gave the following data: (A) Unprotected airway. (B) Angiography showed an active bleeding of a left vesical
Respiratory rate 10/min, insufficient oxygenation, SpO2 artery. A selective embolization with histoacryl was per-
90%. (C) Pulse 50/min, RRsys 152 mm Hg. (D) GCS 5, formed (e–f). The patient thereafter became hemodynam-
pupils symmetric with no response to light. (E) Multiple ically stable and was transported to the intensive care unit
contusions. Prehospital treatment of the emergency phy- for further stabilization. Secondary surgical procedures
sician included intubation, volume therapy of 1,000 ml included osteosynthesis of the subtrochanteric femoral
crystalloid and 500 ml of colloids, and intermittent use of fracture with a dynamic hip screw, cerclage, and long tro-
vasopressors. On arrival to the emergency room, the chanteric plate (day 3) (g–i). Debridement, VacuSeal
patient was in severe shock with a base excess of application, secondary closure with skin graft of the
−19.5 mmol/l, hemoglobin of 7.2 g/dl, and a core body lower leg (multiple surgeries between day 8 and 31). The
temperature of 34.6 °C. Initial radiographic examination patient survived the accident and was discharged after
revealed the following injuries: serial rib fractures (AIS 54 days in hospital with a Glasgow Outcome Scale (GOS)
3) with pneumothorax (AIS 2) and diaphragmatic rupture of 5 (good recovery). (a) A.p. overview of the thorax after
(AIS 4) (a). Fracture of the 1st lumbar vertebra AO-spine chest tube insertion on the left. It shows a severe left-
type B1 (AIS 3). Multiple mesenteric vascular lesions of sided lung contusion and an intrathoracic shadow above
the distal ileum (AIS 4) (b). Vertically unstable. AO-type the left diaphragm, which is compatible with a left-sided
C1 pelvic ring injury (AIS 4). Left-sided transforaminal diaphragmatic rupture and intrathoracic localization of
sacral fracture and bilateral pubic rami fractures (c). intestines. (b) Axial CT cut through the abdomen show-
Intertrochanteric femoral fracture with long lesser tro- ing intraperitoneal free fluid. (c) Axial CT cut through the
chanter fragment (AIS 3) (d). The calculated ISS was 48, level of S1, showing a sacral transforaminal fracture on
NISS 48, TASH 14 points (23% risk), and a RISC II prog- the left with severe displacement. (d) Coronal CT recon-
nostic survival score of 7.6%. Emergency interventional struction of the pelvis and lower extremities showing the
and surgical procedures included chest tube insertion on unstable intertrochanteric fracture on the left with a long
the left side, closed reduction and left-sided insertion of lesser trochanter fragment. (e) Intraoperative view of
two “antishock” iliosacral screws in S1, and closed reduc- angiography showing an active bleeding of a left vesical
tion and bilateral insertion of retrograde transpubic artery. (f) Intraoperative view of angiography after selec-
screws. Laparotomy, removal of abdominal hematoma, tive embolization shows no arterial bleeding anymore. (g)
reduction of intestinal content out of the left thorax, clo- Pelvic a.p. overview taken after the secondary operative
sure of diaphragmatic rupture, and ligation of the mesen- procedure shows two iliosacral screws in S1 on the left
teric vascular lesions of the distal ileum. Resection of side and bilateral retrograde transpubic screws. (h) A.p.
ilium was not necessary. Fasciotomy of the left lower leg overview of the left proximal femur after osteosynthesis
due for compartment syndrome. During the ER and pri- of the intertrochanteric fracture with a dynamic hip screw
mary surgical phase, the patient received 26 PRBC, 16 (DHS) with long femoral plate, cerclage wires, and a but-
FFPs, and 4 TC. After these emergency procedures, the tress plate. (i) Lateral view of the proximal femur after
patient remained hemodynamically unstable despite osteosynthesis with DHS, cerclage wires, and buttress
ongoing resuscitation. It was decided to perform an plate
23  Principles of Damage Control in the Elderly 257

e f

g h i

Fig. 23.2 (continued)
258 P.M. Rommens and S. Kuhn

reasons for early surgery. Noncomplicated frac- r­ ecommendations as for primary surgery: do not
tures (e.g., proximal humerus, distal radius) can harm [65, 66]. This means that necessary surgi-
be treated secondarily during later operative cal interventions will better be divided into con-
phases. Splints or plaster casts are used before secutive operative phases instead of one longer
surgery. Careful padding of the soft tissue enve- procedure. Between these interventions, the
lope prevents pressure sores or neurovascular patient will return to the intensive care unit and
damage. be prepared for further surgery. The sequence of
Injuries of the spine are not subject of emer- interventions will be guided by the urgency of
gency and damage control operations. The only the procedures. Second-look procedures after
exception is a partial and progressive paresis damage control laparotomy or pelvic packing
due to a posttraumatic instability of the vertebral have the highest priority together with soft tissue
column. But even then, life has a higher priority debridement of open and contaminated wounds.
than paresis. Long-lasting spine surgery should Exchange of external fixation to intramedullary
not be done in a borderline patient. Due to low nailing of shaft fractures of the femur or tibia has
bone mineral density, it may be difficult to dis- lower priority, but needs to be done at an early
cover posttraumatic anomalies in the bony struc- stage. Early nailing after external fixation can be
tures of the spine. It is recommended to perform done as a one-step procedure while avoiding
a total body CT scan, which enables an analysis deep (intramedullary) infections due to pin track
of the whole vertebral column, to discover such infections [67].
lesions [64]. An MRI gives specific information Operative stabilization of injuries of the spine
on damage of the ligaments and degree of steno- or posterior pelvic ring needs thorough preopera-
sis at the spinal canal. The last examination is tive planning. The patient must be in such a good
not available in the emergency setting. It should condition that he/she endures a surgical proce-
only be performed at a later stage for answering dure of several hours with a moderate amount of
specific questions such as degree of disco-liga- blood loss and being in the prone position [68].
mentous instability, myelin contusion, and intra- The patients benefit when the surgery is done as
spinal hemorrhage. Operative fixation is early as possible [69].
advantageous in patients with an unstable spine. Open reduction and internal fixation of (juxta)
Nonoperative treatment was associated with a articular fractures and of fractures of the upper
higher mortality in a retrospective study on 154 extremity have a lower priority than the above-
severely injured patients with a mean age of mentioned procedures. Nevertheless, these oper-
76 years [24]. Timing of operation is depending ations should be done within 3 weeks after
on the physiologic condition of the patient. It trauma at the latest. Due to scar tissue formation,
must be possible to place the patient for several mobilization of fracture fragments becomes
hours in the prone position on the operation more difficult, and exact reduction is less easily
table [65]. achieved [70].

Conclusion
23.4.4 Secondary Operative Phases Due to their limited physiologic reserves,
morbidity and mortality of elderly patients
After primary surgery, which is kept as less after high-­energy trauma are higher than in
aggressive and less time-consuming as possible, younger adults. Less severe trauma can lead
the patient is sent to the intensive care unit, to more and more severe complications than
where his/her physiologic condition will be opti- in younger patients. It is of great importance
mized. Second-look surgery and reconstructive to recognize the threat trauma has on the
procedures must be scheduled in intense elderly person, making a correct initial tri-
­cooperation with the intensivist. Timing of fur- age essential. Specific triage criteria must be
ther surgical procedures will follow the same applied for the elderly trauma patient.
23  Principles of Damage Control in the Elderly 259

Elderly persons ­ suffering several injuries 5. http://www.traumaregister-dgu.de/fileadmin/user_

should be sent to a trauma center immedi- upload/traumaregister-dgu.de/docs/Downloads/
TR-DGU-Jahresbericht_2015.pdf.
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guided by the recommendations “save life patterns of complications in elderly trauma patients
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56. Papakostidis C, Giannoudis PV. Pelvic ring injuries with Rommens PM. Intramedullary nailing after external
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A. Selection of patients with severe pelvic fracture delayed stabilization in severely injured patients with
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 Damage Control in Vascular Injury
24
L.P.H. Leenen

The highest goal in damage control surgery is to be performed, and the invention of resuscitative
stop the bleeding. Major injuries to the vessels endovascular balloon occlusion of the aorta
therefore pose the major challenge in the damage (REBOA) have revolutionized the treatment of
control approach. Vascular injuries of the torso the patient with vascular injuries.
are an immediate threat to the life of the victim, The hemodynamically unstable patient is
whereas vascular injuries to the extremity threat nowadays preferably received in a hybrid operat-
the preservation of the limb. ing room with diagnostic CT capabilities.
Early adequate diagnostics by CT and/or angio However still not the standard, the current knowl-
CT even in the hemorrhagic-threatened patient edge calls for such a facility to optimize quick
that seems to be feasible in treatment early on is and precise diagnostics by whole-body CT and
possible in the same location, not losing much immediate possibilities for catheter-guided treat-
time by transportation between locations within ment of compelling bleeding.
the hospital. This has major implications for the However diagnostic and treatment protocols
patient with vascular, profound bleeding patients. are to be adjusted as they are considerably differ-
Early pinpointing of the vascular injury and ent from the standard ATLS protocols and trauma
readily treatment with catheter-guided emboliza- team approach [1]. Only if the circumstances are
tion and balloon control of the lesion will further accommodated to the infrastructure we can enter
expedite control and treatment of these injuries the new paradigm shift.
and opens a new era in damage control of vascu-
lar injuries.
Of course adequate selection of these patients 24.1 REBOA
is of the essence.
Over the past years, major changes have taken For many years uncontrollable hemorrhage in the
place in the management of vascular injuries. abdomen and the pelvis was thought to be best
The invention of hybrid rooms, where both treated with left anterolateral thoracotomy and
operative and catheter-guided interventions can cross clamping the thoracic aorta and subse-
quently increasing blood flow to the brain and
heart. Nevertheless in this heroic procedure, the
L.P.H. Leenen, MD, PhD, FACS results remained dismal. Already in the 1950s,
Department of Trauma, UMC Utrecht,
balloon occlusion of the aorta was performed [2].
Heidelberglaan 100, 3584 CX Utrecht,
The Netherlands Only in the recent years when endovascular treat-
e-mail: l.p.h.leenen@umcutrecht.nl ment of aortic aneurysms was popularized and a

© Springer International Publishing AG 2017 263

H.-C. Pape et al. (eds.), Damage Control Management in the Polytrauma Patient,
DOI 10.1007/978-3-319-52429-0_24
264 L.P.H. Leenen

wide variety of vascular diseases were treated throughout the United States and in Japan.
endoluminally, new interest was pointed to the Recent case reports and multi-institutional trials
use of large balloon catheters to control noncom- have demonstrated safe and effective control of
pressible hemorrhage. Already in non-­heartbeating hemorrhage using REBOA in patients with life-­
donor procedures, catheters have been used to threatening hemorrhage below the diaphragm
occlude the aorta above and below the renal arter- [7, 8].
ies to perfuse the kidneys for preservation with a
total blockage of the aorta, even without the need
of fluoroscopic control. 24.1.1 Indications
After a series of preclinical experiments [3, 4],
it was noted that this procedure had physiologic Indications and contraindications for REBOA are
benefits for abdominal and pelvic hemorrhage indicated in Fig. 24.1. In short any of the indica-
and shock. Thereafter it was used increasingly in tions for an emergency room thoracotomy are
humans [5, 6]. also an indication for this procedure, added with
The REBOA was further revolutionized by a severe pelvic trauma with severe hemorrhage. A
group of physicians in several trauma centers protocol is depicted in Fig. 24.1.

Hypotensive (SBP<90)
partial or non-responder

Access common femoral artery for REBOA

Yes CXR
No REBOA No
Possible aortic injury

Position REBOA in
ZONE 1, inflate and
FAST
proceed to Yes
Positive?
emergent
laparotomy

Position REBOA in Pelvic x-ray

No No
ZONE 1, and inflate fracture?

Position REBOA in
Yes
ZONE 3, and inflate

REBOA protocol after Adams Cowley Shock Trauma Baltimore

Fig. 24.1  REBOA protocol. Modified after Shock Trauma Baltimore

24  Damage Control in Vascular Injury 265

24.1.2 Technique 24.1.4 Courses

The technique can be performed safely in the Currently REBOA is coming to adulthood. There
resuscitation suite using X-ray or in the operating are currently several published training courses
room using fluoroscopy. Recently a non-­ like the Basic Endovascular Skills for Trauma
fluoroscopic technique was introduced [9]. (BEST™) and Endovascular Skills for Trauma
The technique is among others nicely outlined and Resuscitative Surgery (ESTARS™) designed
in the article of Stannard et al. [10]. It consists of to familiarize physicians with the basic endovas-
five steps: arterial access, balloon selection and cular techniques required to perform the REBOA.
positioning, balloon inflation, balloon deflation,
and sheet removal.
The procedure usually is performed as a 24.2 Hybrid Rooms
Seldinger technique. The femoral artery is
approached percutaneously however preferably The advent of the hybrid operating room coupled
by cut down, and a 12 French catheter is advanced with the benefits of endovascular techniques in
over the wire through the artery into the aorta. the setting of trauma will likely result in an
Some authors prefer to use ultrasound to localize increasing number of patients being diagnosed
the artery in the severely hypotensive patients, and treated with catheter-based interventions.
while others rely on the rather invariable ana- The combination of both catheter-guided and
tomic landmarks. damage control operative care makes it possible to
Typically there are two zones of interest use both techniques in the same patient without the
(Fig.  24.1), zone 1 where the balloon is placed need for dangerous transport of a hemodynamically
just above the diaphragm, to control both the jeopardized patient. In the case of a damage control
abdominal viscera and the pelvis, or in zone 3 procedure, catheters can be used intraoperatively
just above the bifurcation to control the pelvis for additional diagnostics, e.g., in a patient after
and the lower extremities. packing of the liver and ongoing intraparenchymal
Consequently injuries can be addressed, arterial bleeding, followed by catheter-guided ther-
whereafter the balloon can be withdrawn, to apy with balloon occlusion or embolization.
avoid further metabolic problems and/or severe Over the years an increasing indication was
repercussion injury and a severe systemic inflam- noted for intra-arterial interventions already for
matory response. over a decade as documented, e.g., by Pryer and
co-workers [11]. A combination of open opera-
tive intervention and intra-arterial adjuncts like
24.1.3 Complications stenting and embolization is more and more
found to be indicated trying to combine less
As with any invasive procedure, complications ­invasive and more targeted treatment of visceral
can occur. In the first place, the catheter is a fairly bleeding [12] as well as pelvic bleeding.
large-bore catheter, with the usual problems of Different authors have presented combined
discrepancy between vessel diameter and the solutions where optimized combined care can be
catheter. Advancement in older people with tortu- delivered [13].
ous iliac vessels can be a problem and in the hec- The ultimate trauma diagnostics, resuscitation,
tic circumstances in the ER could cause and treatment room have been designed and real-
perforation of the vessel. However many of these ized in Switzerland [14], where CT, angio, and
problems have been noted in the endovascular operating facilities have been realized (Fig. 24.3).
procedures currently in vogue in vascular
surgery.
As noted in the paragraph above, if the bal- 24.2.1 General Operative Techniques
loon remains too long in place, severe repercus-
sion problems can occur, leading to severe In general in damage control, simple techniques
inflammatory sequelae. have to be employed in order to gain control as
266 L.P.H. Leenen

quick as possible. Time-consuming complex

repairs are most times not indicated and result in
the loss of the patient and most times on the oper-
ating table.
Draping in case of suspicion of major vessel Zone 1
injury should be from sternal notch to the knees,
as it might be possible to regain control of in- and
outflow in adjacent compartments.
In damage control situations, only a limited
number of preoperative measures and diagnostic
Zone 2
procedures are possible. In modern trauma care,
airway, breathing, and circulatory management
should be simultaneous.
Zone 3

24.2.2 Temporary Occlusion

In the prehospital or preoperative situation

with extensive external blood loss, temporary
occlusion with simple manual or digital pres-
sure provides a simple effective measure for
reduce further blood loss. Alternatively a tour-
niquet in extremity injury can be applied. After
being banned from clinical practice, because of
the danger of venous congestion and the immi-
Fig. 24.2  Aortic zones: Zone 1 from subclavian arteries
nent danger of further damage by injudicious to the diaphragm, Zone 2 visceral arteries, and Zone 3
application, it is back as a result of the Iraqi (from renal arteries to iliac bifurcation)
conflict where it found renewed interest
[15–17].
Another adjunct to temporary tamponade is Intraluminal balloon occlusion can be used intra-
the extraluminal balloon tamponade, which can operatively if the vascular structure can be read-
be utilized in a wide variety of situations and ily identified. Also in- and outflow control can be
anatomic localizations. A Foley catheter is obtained with rubber ­tourniquets, without fur-
placed through the trajectory of the injury and ther damaging vulnerable vascular structures
the balloon is inflated. Slight traction may bol- (Fig. 24.4).
ster the effect. If the opening in the skin is too
wide, it can be sewn together to minimize the
opening. 24.3 Flow Restoration
Intraoperatively bleeding can be stopped or
diminished by manual compression or swabs on 24.3.1 Shunts
the in- and outflow trajectory. In low-pressure
systems, e.g., veins, which are easily damaged In recent years intraluminal shunts have been
by clamping or attempts to dissect this provides used more and more as a temporary vascular
a quick and effective approach to bleeding con- conduit for almost any anatomic location.
trol (Fig. 24.2). For immediate control of abdom- Basic research shows that (Fig. 24.5) even
inal aorta, an aortic occluder (Fig. 24.3) can be under low-­pressure circumstances, the shunt
used (see section on abdominal vessel bleeding), remains patent for a considerable amount of
which is placed in the diaphragmatic aperture. time [18]. Recent experiences in Iraq showed a
24  Damage Control in Vascular Injury 267

ED

Support trolley

2.86 m
Technical

5.70 m
CT OR table
Angio/X-ray

OTs
11.87 m

Fig. 24.3  Combined CT, angio, and OR facilities in one room (From Gross et al., Br J Surg 2010)

Fig. 24.5  Aortic occluder (Stamper)

Fig. 24.4  Swab sticks (Carrico, Thal, Weigelt)

 268 L.P.H. Leenen

huge ­success for introduction of shunts even in have other, potentially bleeding, injuries. The
the field. In a series of 54 shunts placed in the patency of the shunts depends on the physio-
field and 43 in the proximal limb, 37 (85%) logical situation, local circumstances, and time
remained patent until arrival in the definitive of the distal ischemia. Shunts give the opportu-
care area [19]. Even shunts placed in the nity of quick revascularization of the organ or
venous system remained patent [20]. limb, minimizing the acidotic load to the
Commercially available shunts, used for, e.g., patient and minimizing the reperfusion reac-
carotid surgery (Fig. 24.6), can be utilized; tion. The skin can be closed over the shunt
however they also can be constructed from (Fig. 24.7) temporarily, whereafter other inju-
simple iv line or endotracheal suctioning tub- ries can be addressed and/or the patient can be
ing. The shunt is secured from dislodging with further resuscitated in the ICU. Repair of the
a simple tie of any kind, but also sophisticated vessel can be attempted when the patient is in a
clamps can be used when available. more favorable condition and an optimal plan
Shunts can be left in place for a consider- for repair with the optimal operation team can
able amount of time without major drawbacks. be worked out. In case of a concomitant ortho-
The use of anticoagulants is not advised as pedic injury, vascular repair can ensue the
most patients are coagulopatic anyhow and repair of the fracture [21] (Fig. 24.7).

Fig. 24.6  Tourniquets, vessel Pancreas,

loop with tubing Common duodenum
duct retracted

Suprarenal
cava encircled

Normotensive Shock
(Group I) (Group II)
90 90
80 80
70 Control 70
Flow Rate (mL/min)

60 60
Control
50 50
40 40
30 30
Shunted
20 20
Shunted
10 10
0 0
0 6 12 18 24 0 6 12 18 24

Shunt Placed Shunt Placed

Elapsed Time (hours)

Fig. 24.7  Animal lab shunts illustration article

24  Damage Control in Vascular Injury 269

24.3.2 Lateral Repair 24.3.5 Definitive Occlusion

Simple lateral repair, in suitable cases, is prefer- 24.3.5.1 Ligation

able as a quick and effective measure. Lesions of The most simple method for regaining bleeding
larger truncal or extremity vessels can benefit control is clamping and ligation of the bleeder. In
from this technique. The lesion has to be clean a large range of bleeding problems, this remains a
and no devitalization of the vessel wall should be very attractive measure; however every named
present. Also frayed ends or complete transac- artery has its own rules, whether a simple tie will
tion are a contraindication for lateral repair. be tolerated. Care has to be taken in the procedure
Major disadvantage is the high chance to create of clamping. Wild undirected clamping in a pool
a stenosis, even with larger vessels like the aorta of blood results in more damage and vulnerable
or vena cava. If possible the repair should be structures like veins are the first to be severed.
transverse, even in the case of a length tear. Moreover the venous structures are most difficult
Revision of the repair at a second instance is to repair. Controlling inflow and outflow at some
advised and where needed revision before distance in an untouched area can be of great help
thrombosis is apparent. to gain overview. For this a vessel loop passed
twice around a vessel and held in place with a
clip, clamp, or tubing (Fig. 24.4) can be used.
24.3.3 Stents
24.3.5.2 Coiling
With the increased availability of intraluminal A modern way of occlusion of the bleeding vessel
stents, the use in selected cases has picked up. is coiling through the intravascular route.
For numerous indications stents can be used, Although a hemodynamic unstable patient in the
with the major advantage of reducing the opera- angio suite is a bad combination, the disadvan-
tive trauma. Of course in the case of bleeding, tages of additional operative trauma may lead to
covered stents should be used. Main indication this approach. Moreover in a modern combined
for stenting is the thoracic aorta, but also in other operation-angio suite, which should be state of
regions, it has become the method of choice for the art in a level 1 trauma center, the best of these
vascular repair. Upper thoracic aperture vessels two worlds can be combined and a versatile
and axillary but also iliac vessel injuries can be approach to vascular trauma can be utilized. Of
treated in this way in a damage control fashion. course the nature of the bleeding must be arterial.
There is considerable debate whether these stent
procedures should be regarded as bridge proce- 24.3.5.3 Hemostatic Agents
dures, with removal of the stent and direct repair and Glues
in a later phase. As most patients are young and In the case of severe bleeding and devastating
the natural course of these stents is still unknown, wounds, sorting out the exact bleeding focus can
there is a tendency to the latter. be very demanding. As these patients are mostly
already coagulopathic, everything bleeds and dis-
criminating between the structures is mostly not
24.3.4 Complex Repairs and Grafts possible. Mainly for the use outside the hospital,
hemostatic agents have been developed, which
In the context of damage control, surgery com- stops the bleeding immediately. These mineral
plex repairs and the use of extended repair and hemostatic agents mainly draw water from the
grafts are a bad choice. The lengthy operations surroundings in an exothermic process develop-
needed are ill advised in a cold coagulopathic ing temperatures up to 55 °C. In a comparative
patient, whereas the quality of the repair in many analysis in an animal model of lethal groin injury,
cases is not optimal because of the time pressure the efficacy of zeolite was compared to classic
the surgeon is confronted with. dressings and other commercially available
270 L.P.H. Leenen

Fig. 24.8 Shunt

hemostatic agents. The results were astonishing for at least 7 days. It therefore can be used as a
where zeolite reduced blood loss 4–180 min after bridging procedure for subsequent stenting or
application to 10 ml/kg body weight and no deaths open repair procedures.
however at the cost of high exothermic reaction
with temperatures up to 55 °C [22] (Fig. 24.8). 24.3.5.4 Amputation
This could be attenuated by modification of the A very definitive way of dealing with a major
zeolite hemostatic dressing [23]. bleeding problem can be amputation. In the case of
Another adjunct to damage control in vascular a mangled extremity, with multiple injuries and
lesions is the use of fibrin sealant. Kheirabadi severe hemorrhage, it is wise to go for an amputa-
et al. [24] evaluated the use of fibrin sealant tion, in order to save the patient. This team decision
dressing in a high-pressure ­vascular lesion ani- should be made early and ­expeditiously to gain
mal model and concluded that fibrin sealant can time and prevent needless blood loss and additional
seal an arterial bleeding and prevent rebleeding shedding of waste products into the circulation.
24  Damage Control in Vascular Injury 271

The preferred technique is a guillotine amputation, hybrid trauma operating room from the trauma ser-
vice perspective: the RAPTOR (resuscitation with
with compressive dressing afterward, to prevent a
angiography percutaneous treatments and operative
lengthy procedure of modeling and flap creation. resuscitations). Injury. 2014;45:1413–21.
The guillotine amputation offers also the opportu- 12. Pryor JP, Braslow B, Reilly PM, Gullamondegi O,
nity to have a second look and to judge whether the Hedrick JH, Schwab CW. Increasing role of angiogra-
phy in trauma. J Trauma. 2005;59:102–4.
remaining tissues are viable and suitable for the
13. Zealley IA, Chakraverty S. The role of interventional
creation of an adequate amputation stump. radiology in trauma. BMJ. 2010;340:c497.
14. Gross T, Messmer P, Amsler F, Fuglistaler-Montali I.,
Zurcher M, Hugli RW, Regazzoni P, Jacob AL. Impact
of a multifunctional image-guided therapy suite on
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 Principles for Damage Control
in Military Casualties
25
John B. Holcomb and Thomas A. Mitchell

25.1 Introduction p­ ossible, avoid the procedures that will prevent

the early evacuation of the patient” [2]. This reso-
Conceptually, damage control principles are nated on the battlefield; however, it wasn’t until
rooted in military origins; the surgical application 1983 that Dr. Harlan Stone, a civilian, reinstituted
is analogous to US Navy terminology for “the rapid packing and termination of the laparotomy
capacity of a ship to absorb damage and maintain in civilian trauma patients when intraoperative
mission integrity” [1]. The interval termination of coagulopathy became excessive [2]. Ten years
an operation has been described with liver pack- later, Rotondo specifically termed the phrase
ing as early as 1908; however, the practice was “damage control surgery” where patients that
ended soon after high infectious rates were iden- underwent damage control surgery with two or
tified [2]. The introduction of a formal laparot- more visceral injuries and/or had a major vascular
omy by World War I improved mortality; however, injury had a markedly higher survival in a small
the essence of damage control surgery was fur- nonrandomized cohort [77% (10 of 13) vs. 11%
ther captured in World War II, as exploratory (1 of 9), p < 0.02]. Currently, more recent publi-
laparotomy became the standard of care for pen- cations have demonstrated an improved 30-day
etrating abdominal trauma, and surgeons gained survival [73.6% vs. 54.8%; p = 0.009] and a
vast experience in comprehending the necessity decreased mean trauma intensive care unit [11 v
for expedited abdominal exploration hemody- 20 days; p = 0.01] stay in patients receiving a
namically unstable patients [2]. Specifically, in massive transfusion that underwent damage con-
the Western desert in 1942, Watts highlighted that trol laparotomy and damage control resuscitation
a war surgeon “must evacuate the wounded with [3]. Although this methodology to appropriately
all possible speed, both to clear the unit and to care for severely injured civilian patients would
restore its mobility…that he must wherever appear to extrapolate well to an austere environ-
ment, the transition to military austere environ-
ments was initially questioned by many.
J.B. Holcomb (*) Damage control surgery was first utilized in
Department of Surgery, University of Texas Somalia in 1993 during the battle of the Black Sea
at Houston, Houston, USA fought by the US Army Rangers in the streets of
e-mail: john.holcomb@uth.tmc.edu
Mogadishu, Somalia; two patients underwent
T.A. Mitchell damage control procedures and subsequently died
Department of Surgery, San Antonio Military
Medical Center, San Antonio, USA [4]. Retrospectively, the utilization of damage
e-mail:thomas.a.mitchell.mil@mail.mil control methodologies prior to the conflicts of

© Springer International Publishing AG 2017 273

H.-C. Pape et al. (eds.), Damage Control Management in the Polytrauma Patient,
DOI 10.1007/978-3-319-52429-0_25
274 J.B. Holcomb and T.A. Mitchell

Operation Enduring Freedom and Operation Iraqi 2004 [JTTS CPG: damage control resuscitation
Freedom was questioned “because the ­manpower at Level IIb/III treatment facilities].
and material resources are often limited during Furthermore, in order to ensure appropriate
large military mass casualty events, it is question- implementation, evaluation, and scientific inquiry
able whether traditional damage control proce- into the evolution of these damage control tech-
dures should be performed,” as the author notes niques during these conflicts, the “Joint Trauma
that the two patients who underwent damage con- System” was born in May 2004 in order to fulfill
trol laparotomies would likely have been catego- a mission to ensure “that every soldier, marine,
rized as “expectant” if they would have presented sailor, or airman injured in the battlefield or in the
to the combat support hospital later in the fight on theater of operations has the optimal chance for
October 3, 1993 [4]. This logistical concern was survival and maximal potential for functional
propagated in November 2000 by Eiseman et al. recovery” [7, 8]. The collaboration of Surgeons
who postulated that the “enormous logistic General of the US Military, the US Central
requirements for such strategies are contrary to Command, the US Army Institute of Surgical
the demands of the usual wartime scenario. On Research, and the American College of Surgeons
the basis of experience in civilian trauma centers Committee on Trauma formally implemented the
and combat casualty management, we question system in November 2004 [8]. Most importantly,
the suggested extensive role of damage control this effective utilization and organization of
surgery during wartime” [5]. resources has led to a decreased number of sol-
Despite such criticisms, the US military taught diers killed from combat wounds, 8.8% com-
and adopted damage control surgery operative pared to 16.5% during Vietnam [8]. Additionally,
and resuscitative principles at their trauma train- a large focus of the Joint Theater Trauma System
ing centers during the conflicts of Operation Iraqi has been to decrease killed-in-action and died-of-­
Freedom, Operation New Dawn, and Operation wound rates in combat wounded. The Joint
Enduring Freedom in Iraq and Afghanistan. The Theater Trauma Registry has allowed elucidation
damage control techniques and logistics have of the specific mechanisms/etiologies of these
been termed “global combat damage-control sur- two aforementioned categories such that they
gery” and encompass “multiple separate surgical may catalyze future research endeavors to
facilities, multiple surgeons, multiple resuscita- improve overall combat casualty prevention and
tion and stabilization episodes, helicopter evacu- medical intervention.
ation, and fixed-wing evacuations by the Critical Specifically, the dominant injury mechanisms
Care Air Transport Team during a multi-stage during the current conflicts of Operation Enduring
global transit” [6]. Specifically, the operative Freedom and Operation Iraqi Freedom between
techniques remain similar to the civilian setting October 2001 and June 2011 to include 4,596
to include the surgeon implementing damage battlefield fatalities demonstrated that 73.7%
control techniques must be cognizant of their sur- were explosive and 22.1% were gunshot wounds
gical resources, personnel, blood supplies, [7]. Notably, 87.3% of all injury mortality
throughput of current conflict, geographical loca- occurred prior to arriving at a medical treatment
tion, and external weather that plays a direct role facility with three distinct peaks in mortality
in patient transport in comparison to most Level I [35.2% instantaneous, 52.1% were acute (min-
hospitals in the United States that have ample utes to hours: pre-MTF), and 12.7% dying of
personnel, surgical resources, and blood supplies wounds after reaching an MTF) [7]. Most impor-
and do not have to be concerned about transcon- tantly, of the pre-MTF deaths, 24.3% (n = 976)
tinental transfer of their patient. Secondly, the US were deemed potentially survivable with hemor-
military adopted a policy of damage control rhage (90.9%) and airway compromise (8.0%)
resuscitation recommending a 1:1:1 balanced accounting for the vast majority of potentially
resuscitation of packed red blood cells/fresh fro- survivable mortality. Specifically, truncal
zen plasma/platelets codified on December 18, (67.3%), junctional (19.2%), and peripheral
25  Principles for Damage Control in Military Casualties 275

(13.5%) extremity characterized anatomical dis- and (3) complete the mission [10]. Furthermore,
tribution of potentially survivable mortality [7]. it defined the three modalities of prehospital
In succession to this study analyzing death on care – (1) care under fire, (2) tactical field care,
the battlefield, Eastridge et al. also evaluated mil- and (3) casualty evacuation care – with a major
itary patients who “died of wounds” after reach- emphasis on preventing death from the following
ing a military treatment facility. From October potentially survivable mechanisms: (1) extremity
2001 to June 2009, 558 soldiers died of wounds hemorrhage exsanguination, (2) tension pneumo-
[9]. Notably, 51.4% (n = 287) were potentially thorax, and (3) airway obstruction [10]. These
survivable to include 80% which were from acute principles were initially captured by the US
hemorrhage (48% truncal, 31% peripheral Special Operations Command to include Army
extremity, and 21% junctional) [9]. Rangers and Navy SEALS (Sea, Air, and Land
The development of the Joint Theater Trauma Teams) [10]. A study of the 75th Ranger Regiment
System and Joint Theater Trauma Registry and from October 1, 2001, to March 31, 2010,
the deployed research teams has enabled the evo- revealed a 3% potentially survivable death (1 in
lution and scientific inquiry regarding each spe- 32) compared to previous estimations of 24%
cific aspect of military damage control principles. (232 in 982). Furthermore, no casualties died of
These concepts will be further elucidated in the airway obstruction or a tension pneumothorax.
upcoming sections for which acute hemorrhagic The illustration of these important data points
shock remains at the forefront of future research accelerated TCCC guideline recommendation by
to mitigate potentially survivable death at each the Defense Health Board for implementation by
facet of military healthcare which comprises combatant units throughout the DOD [10]. In
damage control principles. addition to fundamentally changing the training
of military medics/soldiers using TCCC, the pre-
hospital environment provides ample opportuni-
25.2 Prehospital ties to implement patient care: (1) tourniquets, (2)
hemostatic dressings, (3) hypothermia preven-
The most impactful focus of damage control sur- tion, (4) airway protection, (5) tension pneumo-
gery/resuscitation remains the prehospital phase thorax, and (6) fluid resuscitation.
of care, as previously mentioned, 87.3% of fatali- First, tourniquets were sporadically utilized on
ties occurred prior to reach a medical treatment the battlefield during the initial conflicts in
facility of which 24.3% were potentially surviv- Afghanistan with the exception of the Special
able [7]. The combination of “temperature and Operation Forces in 2001. However, the prelimi-
weather extremes, severe visual limitations nary evaluation of preventable death on the battle-
imposed by night operations, logistical and com- field from extremity hemorrhage revisited the
bat related delays in treatment and evacuation, necessity of tourniquet implementation. Holcomb
lack of specialized medical care providers and et al. demonstrated from 2001 to 2004 in the US
equipment near the scene, and lethal implications Special Operations Forces that 15% (n = 12) died
of opposing forces” renders prehospital pickup from potentially survivable etiologies to include
and transportation while simultaneously deliver- noncompressible hemorrhage (n = 8) and hemor-
ing optimal healthcare challenging [10]. The rhage amenable to a tourniquet (n = 3) [11].
implementation of civilian Advanced Trauma USSOCOM was the first to mandate tourniquets
Life Support into the austere setting revealed cer- for its deploying combatants in March 2005 [12].
tain deficiencies during Iraq and Somalia in the By 2006, acceptance of tourniquet utilization had
early 1990s [10]. After extensive congressional become widespread. Specifically, Eastridge et al.
inquiries into these disparities in care, an article estimated that the universal implementation of
entitled “Combat Casualty in Special Operations” tourniquets decreased the death rate from
was borne emphasizing three main objectives: (1) peripheral-­ extremity hemorrhage from 23.3
treat the patient, (2) prevent additional casualties, deaths per year (pre-2006) to 17.5 deaths per year
276 J.B. Holcomb and T.A. Mitchell

(2006–2007). Furthermore, Eastridge et al. power source for several hours [14]. In 2006, the
­demonstrated that 19.2% of potentially survivable JTTS published a CPG for hypothermia preven-
death resulted from junctional hemorrhage. Thus, tion and was associated with a decrease in the
current research through the Medical Research incidence of hypothermia a year after implemen-
and Materiel Command initiated pursuit of a junc- tation ([15]/include JTTS hypothermia preven-
tional tourniquet for the inguinal region. There are tion CPG).
now multiple junctional tourniquets approved for Airway protection including tension pneumo-
use on the battlefield and in civilian EMS. thorax decompression with a 5 in. needle and/or
Secondly, hemostatic dressings have under- proficiency with cricothyroidotomy if endotra-
gone an evolution in care throughout Operation cheal intubation cannot be safely performed are
Iraqi Freedom and Enduring Freedom. First, dry further instructive pieces in the TCCC training to
fibrin sealant dressings were utilized, but were thwart potentially survivable deaths [11, 16].
withdrawn secondary to regulatory challenges Prehospital fluid resuscitations per TCCC
and expenses [12]. Secondly, the US Army guidelines specify for the medic to evaluate the
moved to the HemCon bandage which utilizes radial pulse character and/or mental status (in the
freeze-dried chitosan working through tissue absence of traumatic brain injury) to administer
adhesion of the positively charged chitosan with 500 ml of Hextend (Hospira, Inc., Lake Forest,
the negatively charged red blood cells [12]. Illinois), intravenously if the casualty is in shock
Wedmore et al. demonstrated a 97% (62/64) suc- [17]. A repeat bolus is to be given if there is a
cess rate in the cessation or improvement in persistence of shock after 30 min of duration.
hemostasis after the application of a HemCon Crystalloid and colloid resuscitations are to be
bandage from direct verbal reports from combat minimized guided by the principles of a “hypo-
medics [13]. Concurrently, the US Navy utilized tensive” resuscitation (90 mm Hg) to minimize
QuikClot, which was shown efficacious against the sequelae of popping the clot, dilutional coag-
venous and mixed venous-arterial hemorrhage ulopathy, and perpetuating further bleeding,
via a mineral-based (zeolite) agent that absorbs especially in noncompressible torso hemorrhage
water and concentrates blood clotting proteins [17, 18].
with cells rendering hemostasis [12]. Finally, the implementation of rapid evacua-
Unfortunately, the resulting exothermic reaction tion teams within the military prior to arrival at a
caused several severe burns. Further research has medical treatment facility led to the creation of a
demonstrated that Combat Gauze is superior and physician-led evacuation team entitled Medical
has been adopted in the current 2008 TCCC Emergency Response Team (MERT) [12]. The
guidelines [12, 14]. Combat Gauze was identified team consists of a critical care nurse with emer-
to be the most efficacious in a femoral arterial gency medicine background, physician, and a
injury porcine model resulting in an 80% survival paramedic on a CH-47 Chinook in Afghanistan
(8/10) compared to other bandage models; that is capable of carrying eight stretcher cases or
Combat gauze, a product of Z-Medica 20 ambulatory casualties [12]. The guiding prin-
Corporation (Wallingford, CT), is impregnated ciple of moving advanced healthcare team mem-
with contact (intrinsic) pathway activated clot- bers farther forward is to implement further
ting agent known as kaolin [14]. Based on recom- damage control resuscitative and intervention
mendations from TCCC, HemCon and QuikClot principles earlier in the care of the wounded sol-
have largely been abandoned by the DoD. diers. Furthermore, many of the MERT-E
Hypothermia (<35 °C) prevention techniques (enhanced) have four units of O-positive packed
include wrapping casualties in both a wool blan- red blood cells and four units of thawed plasma
ket and a “space blanket”; however, more recent on board to give balanced blood product transfu-
evidence and innovation demonstrated that sion instead of colloid/crystalloid earlier in the
Hypothermia Prevention and Management Kit resuscitations [12]. Finally, the MERT physician
(HPMK) can provide external warmth without a has the option for patients with noncompressible
25  Principles for Damage Control in Military Casualties 277

torso hemorrhage to administer the antifibrinol- high-PLT group (12%) compared to low FFP/low
ytic TXA (tranexamic acid) [12]. PLT (16%), high FFP/low PLT(17%), and low
FFP/high PLT (16%). Notably, the high FFP/high
PLT had the highest ISS of 26. The summation of
25.3 Hospital this presented data gives credence to the mili-
tary’s 1:1:1 resuscitation strategy. Most impor-
Upon arriving at the medical treatment facility, tantly, in massively transfused patients prior to
damage control principles are continued. First, DCR CPG compared to post-DCR implementa-
the resuscitation of patients arriving parallels the tion, the mortality rate decreased from 32% to
damage control resuscitation CPG which empha- 21% [22].
sized two major components: permissive hypo- Additional adjuncts to DCR include TXA
tension and 1:1:1 of plasma/platelet/RBC (tranexamic acid). In 896 casualties at a NATO
resuscitation [19]. The evaluation of a combat Role III in Bastion, Afghanistan, 896 casualties
support hospital between November 2003 and received TXA, and those receiving TXA had a
September 2005 of 246 patients who received a higher survival rate (82.6 vs. 76.1%; p = 0.028).
massive transfusion, defined by a low ratio (1:8), Additionally, in the massive transfusion sub-
medium ratio (1:2.5), and high ratio (1:1.4) of group, the survival rate was 28.1% vs. 14.4%,
pRBCs to FFP demonstrated an overall survival p = 0.004. Finally, TXA was demonstrated to be
of 19%, 34%, and 65%, respectively [19]. independently associated with survival odds ratio
Furthermore, mortality rates from hemorrhage of 7.28 [23].
were 92.5% (low ratio), 78% (medium ratio), and Finally, in addition to traditional coagulation
37% (high ratio), respectively [19]. In massive studies such as Fibrinogen, pT, apTT, and INR,
transfusion resuscitations in 466 civilian trauma newer modalities such as thromboelastography
patients between July 2005 and June 2006, the and rotational thromboelastometry have been uti-
combination of high plasma/pRBC (59.6% vs. lized to further guide resuscitative efforts in the-
40.4%, p < 0.01) and high platelet/pRBC (59.9% ater as early as 2004 [24]. Specifically, Doran
vs. 40.1%, p < 0.01) ratios improved 30-day sur- et al. demonstrated that rotational thromboelas-
vival compared to low plasma/pRBC and plate- tometry compared to traditional coagulation tests
let/pRBC ratios [20]. Furthermore, the (pT/apTT) increased the identification of coagu-
implementation of DCR principles (2006–2011) lopathic patients (64% vs. 10%) in 31 patients in
versus pre-DCR (2002–2006) demonstrated a a deployed setting [25].
decrease in the plasma/RBC ratio from 2.6:1 pre-­ As a direct adjunct to the DCR means of resus-
DCR to 1.4:1, while the concomitant mean ISS in citation, the operative techniques largely are sim-
the cohort increased from 23 to 27 (p < 0.05), ilar to civilian counterparts. However, the one
TRISS decreased to 0.64 (DCR) from 0.77 (pre-­ main divergence is the large preponderance of
DCR), and an average AIS head (4.3 (DCR) vs. explosion injuries that render multiple compo-
3.9 (pre-DCR), p < 0.01) indicates that patients nents of injury. Explosion injuries induce four
post-DCR implementation were more severely different means to cause injury (primary, second-
injured including a greater predominance of trau- ary, tertiary, quaternary). Primary injury is caused
matic brain injury while minimizing the poten- by the contact of the blast shockwave on the body
tially preventable deaths [21]. Ultimately, the such as occasional tympanic membrane rupture,
implementation of DCR principles appeared to lung injury, and concussion [26]. Secondary inju-
have improved survival in less injured potentially ries are caused by ballistic wounds such as frag-
survivable population that may have succumbed ments that induce penetrating injuries, traumatic
during the pre-DCR era. Additionally, from amputations, and laceration [26]. Tertiary injuries
March 2003 to February 2012, 3,632 soldiers are induced from the blast wave propelling sol-
received at least one unit of transfusion, the low- diers onto surfaces and/or objects causing a blunt
est mortality was identified in the high-FFP to injury, crush syndrome, and/or compartment
278 J.B. Holcomb and T.A. Mitchell

s­ yndrome [26]. Finally, quaternary injury results injury at the thoracic outlet, loss of chest wall
from other explosion-related injuries/illnesses requiring subsequent debridement and closure,
such as burns or toxic gases [26]. Therefore, in massive air leak, tracheobronchial injury, esopha-
comparison to standard civilian injuries that can geal injury, and mediastinal are identified [2].
be divergently categorized as blunt or penetrating However, the unnecessary overutilization of DCS
and treated accordingly, the explosion injury is a should be avoided, as inappropriately leaving the
complex hybrid that often has components of abdomen open predisposes patients to subse-
both penetrating and blunt injurious mechanisms. quent complications (Hatch, Holcomb et al.).
This mechanism has been dominant on most bat- Major vascular injuries can be diagnosed 90%
tlegrounds since World War I and the physics of the time based on history and physical exami-
well described. nation evaluating for hard signs of vascular
Interestingly, a primary modality to evaluate injury to include pulsatile bleeding, expanding
penetrating abdominal trauma from World War I hematoma, palpable thrill, audible bruit, and evi-
to 2004 was to explore all patients; however, the dence of ischemia [27]. An ankle-brachial index
implementation of ultrasound and computed and/or injured extremity index should be per-
tomography has enabled visualization and/or formed in conjunction with a physical examina-
estimation of fragment/bullet trajectories to aid tion. Arteriography if available may also be
the surgeon in their decision to explore or to useful for diagnostic purposes. Finally, the
monitor [6]. Beekley et al. demonstrated that Mangled Extremity Score may be used as a guide
60% of all stable patients with penetrating frag- for the surgeon in a deployed setting to guide
ments could undergo selective nonoperative decision-­making whether to amputate or not
management in the absence of frank peritoneal which includes criteria such as (1) skeletal/soft
signs on physical examination and based on CT tissue injury, (2) limb ischemia, (3) shock, and
findings had no intraperitoneal nor retroperito- (4) patient age with a combined score of 7 or
neal penetration of the fragments [6]. Therefore, more that predicts a 100% amputation rate [27].
the deployed military surgeon may utilize focused The utilization of these tools while in theater
abdominal sonography for trauma, physical allows the surgeon to utilize three different gen-
examination, hemodynamic stability, and com- eralized modalities: (1) attempted limb salvage
puted tomography which are screening tests in an with or with vascular repair, (2) damage control
austere environment to assist the decision-­making with the use of shunts or placement of pneumatic
of the surgeon whether or not to explore an abdo- tourniquets, and (3) debridement alone [27].
men. If exploratory laparotomy is performed, Furthermore, important principles while
damage control principles of controlling contam- deployed include adequate debridement of
ination and hemorrhage should be considered wounds and/or placing bypasses through non-­
especially for those who are acidotic, hypother- contaminated fields [27]. Additionally, the utili-
mic, coagulopathic or undergoing a massive zation of systemic heparinization (50–75 units/
resuscitation. A temporary abdominal closure kg IV) must be juxtaposed against the totality of
should be utilized for these patients to allow for injuries the patient has suffered, as this is rarely
further resuscitation in conjunction with a required in theater (28: Starnes). Saphenous vein
second-­look operation to perform definitive man- as opposed to vascular synthetic grafts should be
agement of all identified injuries either at a higher considered in likely contaminated fields. Finally,
echelon of care (NATO Role III from initial shunts such as the Sundt shunt (Integra
NATO Role II) or a second-look operation at a Lifesciences, Plainsboro, NJ) are recommended
NATO Role III MTF, or transferring to a higher if damage control vascular techniques are to be
level of care (NATO Role IV or NATO Role V) employed in conjunction with the liberal utiliza-
with a temporary abdominal closure. Furthermore, tion of fasciotomy incisions [27]. Importantly,
damage control modalities can also be extrapo- the implementation of damage control
lated to the thoracic cavity if major vascular resuscitative strategies has enabled increased
­
25  Principles for Damage Control in Military Casualties 279

efforts toward limb salvage, as opposed to prior flight with an average transit time of 53 h from
doctrine in Vietnam/beginning of conflicts the initial time of application in a deployed envi-
(2001–2003) which stated that amputation was ronment to an operating room at a NATO Level
often necessary in severely injured casualties IV (Outside the Continental United States) well
[28]. Dua et al. document a graft patency of within the standard of 72 h device recommenda-
84.9% in 96 grafts with a follow-up between 29 tion [30]. Fang et al. demonstrated a similar
and 1,079 days with an amputation-free survival effectiveness and safety with the negative pres-
of 84% [28]. Overall, 1,221 soldiers underwent sure wound therapy device in 30 patients who
amputations sustaining a total of 1,631 amputa- underwent successful transcontinental aeromed-
tions from January 2001 through July 30, 2011, ical evacuation with a negative pressure wound
with transtibial (683, 41.8%) and transfemoral therapy. Finally, the aggressive debridement of
(564, 34.5%) being the two most common [25]. these austere wounds emanates from the desire
The overall mean amputation rate was 5.29 per to diminish the superimposition of bacterial and/
100,000 deployed troops [25]. Furthermore, this or fungal superinfections to these wounds which
study identified that 30% of all amputees had prompted the “Treatment of Suspected Invasive
multiple amputations of the lower extremities, Fungal Infection in War Wounds” Clinical
and this was higher than the multiple-amputee Practice Guideline which was first published on
rate from World War I, World War II, the Korean November 1, 2012, which advocates three main
War, and Vietnam War [25]. Furthermore, principles with war wounds: debridement of
Standsbury et al. identified from October 1, infected tissue, minimization of immunosup-
2001, to June 1, 2006, a major amputation rate of pression, and utilization of systemic anti-mold
5.2% for all serious injuries and 7.4% for all medications [JTTS CPG]. Furthermore, this
major limb injuries compared to an 8.3% ampu- CPG advocates early topical antifungal therapy
tation rate in Vietnam [29]. with 0.0025% Dakin’s solution if a patient has
Orthopedic damage control principles entail three of the following risk factors: dismounted
early, rapid, temporary stabilization of a fracture blast injury; above-the-knee amputation; exten-
to minimize blood loss subsequently followed sive perineal, genitourinary, or rectal injury; and/
by physiological resuscitation and then defini- or super massive transfusion of greater than
tive management [6]. External fixation is the 25 units packed red blood cells including whole
most common means of rapidly stabilizing a pel- blood. Finally, a histopathological specimen will
vis and/or long bone fracture. In conjunction be taken at NATO Role IV medical treatment
with extremity fractures, soft tissue injuries have facilities of the wounds, and if two operative
prevailed within the current conflicts of trips have not improved the wound, the patient
Operation Iraqi Freedom and Operation will be empirically started on voriconazole and/
Enduring Freedom secondary to the high-veloc- or liposomal amphotericin B [JTTS CPG].
ity gunshot wounds and explosive blasts that The major advances in burn care reflect
mandate early aggressive operative debridement implementation of a Burn Resuscitation Flow
[30]. A newer modality to dress these wounds Sheet and use of a simplified formulation called
compared to conventional wet-to-dry gauze the Rule of 10 [6]. The Burn Resuscitation
dressings includes the utilization of negative Flow Sheet enables continuity of care through-
pressure wound therapy (V.A.C. Therapy, KCI out the geographical movement, such that every
Licensing, Inc., San Antonio, TX). For instance, provider will know specifically how much fluid
one retrospective study evaluated 218 patients in the patient has received in transit to avoid com-
combat who had 298 separate sites and 1.37 plications such as abdominal compartment syn-
wound sites per patient; Pollak et al. demon- drome from over-resuscitations. From January
strated that negative pressure wound therapy 2003 to June 2007, 598 military casualties of
could be utilized effectively and safely in an aus- which 118 had greater than 30% total body sur-
tere environment that involves a transcontinental face area burns [31]. The implementation of a
280 J.B. Holcomb and T.A. Mitchell

burn resuscitation guideline in January 2006 25.5 Summary

resulted in a non-­ statistically significant
decrease in overall abdominal compartment The preceding sections outline the changes that
syndrome (5% vs. 16%; p = 0.06) and mortality have occurred in battlefield care from 2001 to
(18% vs. 31%; p = 0.11); however, the compos- 2014. Largely, these changes have been centered
ite end point of abdominal compartment syn- on the damage control concept of early aggressive
drome and mortality was statistically significant intervention, pushing interventions into the prehos-
(18% vs. 36%; p = 0.03) [31]. Additionally, the pital area, a focus on restoration of normal physiol-
Rule of 10 enables for calculation of the initial ogy, multiple operations, and rapid evacuation to a
fluid rate in the resuscitation which is 10 cc/h * higher level of care. Under the leadership of the
% t to avoid arbitrary starting points [6]. Joint Trauma System, these integrated changes
Furthermore, the most common topical antimi- have resulted in a low case fatality rate. However, it
crobial is silver sulfadiazine and Sulfamylon is incumbent on us to recognize that there are still
cream in addition to negative pressure wound far too many potentially preventable deaths and
therapies that are being utilized more frequently avoidable morbidity, and we must work together to
after early excision of burn wounds [6]. improve outcomes on the next battleground.

25.4 Aeromedical Evacuation

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hemorrhage in swine. J Trauma. 2009;67(3):450–9. 25. Doran, et al. Feasibility of using rotational throm-
15. Palm K, et al. Evaluation of military trauma system boelastometry to assess coagulation status of com-
practices related to damage-control resuscitation. bat casualties in a deployed setting. J Trauma. 2010;
J Trauma Acute Care Surg. 2012;73:S459–64. 69(Suppl 1):S40–8.
16. Blackbourne, LH. 1831. Army Med Dep J. 2011. 26. Champion HR, et al. Injuries from explosions: phys-
17. Blackbourne LH, et al. Decreasing killed in action and ics, biophysics, pathology, and required research
died of wounds rates in combat wounded. J Trauma: focus. J Trauma. 2009; 200966:1468–77.
Inj Infect Crit Care. 2010;69(1):S1–4. 27. Starnes BW, et al. Extremity vascular injuries on

18. Blackbourne, LH et al. Joseph Lister, noncompress- the battlefield: tips for surgeons deploying to war.
ible arterial hemorrhage, and the next generation of J Trauma. 2006;60:432–42.
“tourniquets”. Army Med Dep J. 2008;56–59. 28. Dua A, et al. Long-term follow-up and amputation-­
19. Borgman MA, et al. The ratio of blood products
free survival in 497 casualties with combat-related
transfused affects mortality in the patients receiving vascular injuries and damage control-resuscitation.
massive transfusions at a combat support hospital. J Trauma Acute Care Surg. 2012;73:1517–24.
J Trauma. 2007;63:805–13. 29. Stansbury, et al. Amputations in U.S. military person-
20. Holcomb JB, et al. Increased plasma and platelet to nel in the current conflicts in Afghanistan and Iraq.
red blood cell ratios improves outcome in 466 mas- J Orthop Trauma. 2008;22:43–6.
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 Penetrating Injuries and Damage
Control Surgery: Considerations
26
and Treatment Options

Oscar J.F. van Waes and Michael H.J. Verhofstad

26.1 Introduction 26.2 General Considerations

with Regard to Penetrating
For most trauma care providers, patients in need of Injuries and Damage Control
DCS due to penetrating injury are still a rarity. Management
This certainly accounts for the bigger part of
Western Europe [1–4]. There are, however, some Trauma mechanisms for penetrating injury (PI)
indications that the number of patients suffering are classically described as being either high- or
from PI is slightly rising [5–7], if not for the least low-velocity injuries. Stab injuries with knives or
under victims of terrorist attacks [8, 9]. Another sharpened object were recognized as low-­velocity
argument to elaborate on this specific trauma PI. As for gunshot wounds a differentiation was
mechanism is that these patients are known self-­ proposed based on the muzzle velocity of the
referrals who can present themselves at any emer- projectile. A more sensible discrimination can
gency department of even the smaller peripheral however be made by the amount of energy the
hospitals with a seemingly minor injury rapidly projectile transfers to the body [10]. So it is pos-
deteriorating into a resuscitative setting. Hence the sible that, for example, an AK-47 bullet, with a
authors will present in this chapter general consid- muzzle velocity of 1,100 m/s, will hit a victim
erations and body region specific treatment options placed several hundred meters away from the
for patients suffering from penetrating injury (PI) assailant only with enough energy to penetrate
and who are in need of DCS. the skin and subcutaneous tissue. This gunshot
wound (GSW) can then be considered a low-­
energy transfer (LET) injury, similar to a small
caliber pistol injury. However, a close range pis-
tol GSW can reveal a high-energy transfer (HET)
concomitant injury such as devitalization seen by
the temporary cavitation caused by the shock-
wave of the passing projectile (Fig. 26.1). Though
O.J.F. van Waes (*) • M.H.J. Verhofstad notably inconclusive (“minding his own business
Trauma Unit, Department of Surgery, Erasmus MC, when suddenly attacked by strangers”), a history
University Medical Center Rotterdam,
Rotterdam, The Netherlands of a patient suffering from PI might render
e-mail: ovanwaes@gmail.com; ­information whether he might suffer from HET
m.verhofstad@erasmusmc.nl or LET. This information could, for example,

© Springer International Publishing AG 2017 283

H.-C. Pape et al. (eds.), Damage Control Management in the Polytrauma Patient,
DOI 10.1007/978-3-319-52429-0_26
284 O.J.F. van Waes and M.H.J. Verhofstad

a b

c d

Fig. 26.1 (a–c) A HET projectile (a) causing not only patient was treated with staged surgery (d). After 12 h
penetrating injury to the cecum (b) but also ischemia of definitive surgery with ileocolic anastomosis was
the whole cecum and ascending colon (c); hence the performed

support the surgeon’s decision to perform staged to miss PI. It is advisory to mark all wounds.
surgery for injuries to the gastrointestinal tract to Paperclips can be bend a P or A shape, as to indi-
assess the vitality before performing a definitive cate the posterior or anterior side of the patient
anastomosis in (suspected) HET PI. On physical (Fig. 26.2). This is helpful to assess which body
examination all clothing should be removed as cavities or organs might be injured. It should be
soon as possible to exclude additional injuries of mentioned though that the projectiles might not
which the patient or prehospital emergency ser- have traveled through the tissue in a straight line.
vices personnel was not aware. Special care In case of GSW the number of paperclips should
should be given to junctional areas (axillae, groin, be an even number (entry wound corresponding
neck) and skin folds, since these areas are prone with exit wound) or corresponding with a bullet.
26  Penetrating Injuries and Damage Control Surgery: Considerations and Treatment Options 285

Fig. 26.2  X-ray without (a) and with paperclip markers (b). The A-shape bend paperclips indicate three anterior gun-
shot wounds corresponding with three bullets

When an uneven number is counted, not matched Glasgow coma score of 3 and over, after success-
with a projectile, the examiners should depict the ful resuscitation with CT scan proven mass lesion
adjacent body regions with X-rays until the bullet effect, should undergo decompression via crani-
is found, if the hemodynamic status of the patient ectomy (Fig. 26.3) as soon as possible to improve
allows [11, 12]. survival and outcome. Patients who display a
“tram-track sign” caused by cavitation of a pass-
ing projectile, or those with transventricular
26.3 D
 amage Control Options injury approximately 4 cm above the dorsum sel-
for Penetrating Injuries lae, the so-called zona fatalis, will not benefit
to the Head and Neck from decompression and should be treated expec-
tantly [18–20]. If the patient’s hemodynamic sta-
As mentioned prior the amount of energy, which tus does not permit a CT scan of the brain,
is transferred to patient’s tissue, indicates the out- synchronous damage control surgery by both
come. This is certainly true for gunshot wounds trauma surgeon and neurosurgeon can be per-
to the brain. Though it should be mentioned that formed if a mass effect due to the penetrating
not all gunshot wounds to the brain are lethal. brain injury is suspected. If the measured intra-
The recent military conflicts in Iraq and cranial opening pressure does not warrant diag-
Afghanistan produced data in which rapid dam- nostic burr holes and damage control surgery
age control craniectomies for penetrating brain has been successful, a CT scan of the brain
injuries produced an increase in survival [13–15]. should be acquired as soon as possible to assess
In civilian practice these aggressive damage con- brain injury and treatment options [16]. For stab
trol resuscitation and neurosurgical treatment wounds to brain with sharpened objects, apply
strategies have also been successfully imple- the same indications for neurosurgical treatment
mented, under the adagium “time is brain” [16, as for gunshot wounds with exteriorized
17]. Patients with brainstem reflexes and a objects in situ as additional indications (Fig. 26.4)
286 O.J.F. van Waes and M.H.J. Verhofstad

a b

Fig. 26.3  Clinical presentation (a) and CT planogram (b) of HET gunshot wound limited to one hemisphere as indica-
tion for decompression via craniectomy (c)

a b

Fig. 26.4  Clinical presentation (a) and X-ray (b) of an exteriorized knife still in situ

[21–23]. Penetrating injury to the neck can gen- rush to theater for surgical exploration, with an
erate a p­ redicament, especially when gross bleed- increased risk on iatrogenic injury [26, 27]. Foley
ing is noted [24, 25]. In low-volume centers for catheter balloon tamponade can be used as a
penetrating injury, there might be the tendency to damage control resuscitative tool to regain
26  Penetrating Injuries and Damage Control Surgery: Considerations and Treatment Options 287

a b

Fig. 26.5  Rushed into exploration of a penetrating neck (b), thus creating a controlled situation for the patient to
injury with considerable change of iatrogenic injury (a). be assessed for vascular or hollow organ injury via com-
Foley catheter balloon tamponade achieving hemostasis puted tomography angiogram of the neck (c)

h­ emodynamic stability and temporary hemosta- the carotid vessels if the patient’s condition does
sis to bridge to endovascular or surgical treat- not allow definitive primary repair or an interpo-
ment after CTA assessment of the neck (Figs. sition graft. For bailout options in case of persis-
26.5 and 26.6). When no arterial bleeding needs tent bleeding in which suture techniques might
to be addressed, the catheter is deflated and not be successful, such as injury to vertebral
removed in controlled surroundings. Successful artery, again Foley catheter balloon tamponade
conservative treatment for penetrating neck can be used or hemostatic granules or bone wax.
injury, when using this strategy, can be 87% [28]. Esophageal injury repairs, especially in combina-
When surgical exploration is indicated, the sur- tion with tracheal injury, should be protected
geon should be familiar with shunts suitable for with mobilized strap muscle and a drain.
288 O.J.F. van Waes and M.H.J. Verhofstad

Fig. 26.6  Flowchart for management Penetrating neck injury

of penetrating neck injury with
optional Foley catheter balloon
tamponade
ATLS®

No Yes
Active bleeding? FCBT

No
Shock?

Yes
CTA Bleeding controlled?
Yes
No

Observation 48h Radiological

Endoscopy intervention Surgery
(TABLE 1)

26.4 D
 amage Control Options approach is standard for an emergency depart-
for Penetrating Injuries ment thoracotomy. The pericardium should
to the Chest always be opened as soon as possible, since from
the outside it cannot be assessed for the presence
For penetrating injuries of the chest, it should be of a hemopericardium. Opening of the pericar-
mentioned that gunshot wounds, especially with dium, ventral to the phrenic nerve, has the addi-
an oblique trajectory, are likely to perforate the tional benefit of being able to perform more
diaphragm and thus might inflict intra-abdominal efficient cardiac compressions. For massive pul-
injury. This indicates that patients should have monary bleeding, clamping of the lung paren-
sterile exposure and surgical draping that, if chyma or hilium is an option. Another alternative
needed, allows an additional laparotomy when is the so-called pulmonary hilar twist, in which
the primary surgical exploration is a sternotomy the apex of the lung is twisted downward to the
or thoracotomy (Fig. 26.7). In case of a transient diaphragm and the lower lobe upward after
or nonresponder to resuscitation with a systolic release of the inferior pulmonary ligament [32].
blood pressure that cannot be raised over Simple suture closure of perforating brisk bleed-
60 mmHg in the shock room, a resuscitative tho- ing lung injuries is not an option, and the devel-
racotomy is indicated [29, 30]. This also applies opment of intrapulmonary hematoma or a
for patients suffering from penetrating chest possible air embolism can only be prevented by
injury with witnessed cardiac arrest. Though performing a pulmonary tractotomy. This can be
there is no global consensus with regard to the achieved by “connecting” the entrance and exit
“downtime” after which an emergency thoracot- (or creating an exit) wound of the lung paren-
omy is still justified, it is generally accepted that chyma using a GIA stapler. The injured vessels
survival for patients with ongoing cardiopulmo- and bronchi which have not been sealed by sta-
nary resuscitation longer than 15 min is nil [31]. ples can then be selectively ligated (Fig. 26.8)
Unless the injury is clinically limited to the right [33]. In order to limit the circulation to the chest
side of the chest, a left-sided anterolateral and head while other resuscitation techniques are
26  Penetrating Injuries and Damage Control Surgery: Considerations and Treatment Options 289

a b

Fig. 26.7  Penetrating injury to the chest with both pericardial and subdiaphragmatic injury (a), indicating a sternolapa-
rotomy (b). Full sterile exposure facilitated a swift extension from sternotomy to laparotomy

a b

c d e

Fig. 26.8  A gunshot wound to the left lung (a). A tractotomy using a GIA stapler (b, c) and selective ligation of bronchi
and vessels with persistent leakage (d, e)
290 O.J.F. van Waes and M.H.J. Verhofstad

applied such as placement of central lines, the dial sac is approached preperitoneal, aided by
aorta can be clamped. Positioning of the clamp elevating the xyphoid process with a clamp. If the
can be cumbersome in a flaccid aorta. It is more evacuated fluid from the pericardium is clear or
practical to compress the aorta to the vertebral serosanguinolent and remains clear after rinsing
column with fingertips. After successful adminis- with saline, the drain production can be moni-
tration of circulating volume, the aorta will be tored. When blood is encountered, the procedure
pulsatile again with a normal caliber and easier to should be converted to sternotomy for most likely
clamp. If the injury is trans-mediastinal or injury myocardial repair [35–37] (Fig. 26.9). Small
to other side of the chest is suspected, the thora- injury of the right side of the diaphragm can be
cotomy can be extended by cutting the sternum repaired if easily reached by limited mobilization
and the intercostal musculature of the right side of the liver to prevent the possibility of bile leak-
of the chest into a so-called clamshell thoracot- age in the pleural cavity. Left-sided diaphrag-
omy with an excellent exposure of both left and matic injuries always need closure with
right side of the thorax and mediastinum [34]. In nonabsorbable sutures to prevent future compli-
patients in extremis with a penetrating injury tra- cation (e.g., intrathoracic herniation of peritoneal
jectory that is suspected for pericardial injury and content). In case of gross intra-abdominal fecal
in whom the clinical status did not allow assess- spillage, the laceration can be enlarged, parallel
ment of the pericardium via CTA or ultrasonog- to the phrenic innervation, or using an additional
raphy, a “subxiphoid window” procedure should incision posterolaterally in a curvilinear orienta-
be performed prior to laparotomy. The pericar- tion to facilitate washout of the pleural cavity

a b

Fig. 26.9  A subxiphoid window procedure for a suspected pericardial injury (a). Clear fluid can be monitored using a
drain for 12 h. Bloody effusion (b) indicates conversion to a sternotomy (c)
26  Penetrating Injuries and Damage Control Surgery: Considerations and Treatment Options 291

with several liters of saline to diminish the Kocher’s maneuver is mandatory if a duodenal
­bacterial load and change of formation of pleural injury is suspected. Primary tensionless repair of
empyema [38]. duodenal lacerations should be attempted and
concomitant pancreatic injuries are to be drained.
The suture line can be protected with decompres-
26.5 D
 amage Control Options sive jejunal-cutaneous fistula using (Foley) cath-
for Penetrating Injuries eters and optional a more distal one for enteral
to the Abdomen feeding. Another possibility to spare the duode-
nal repair is by pyloric exclusion [40]. However,
A fair number of tangential abdominal gunshot these procedures are time demanding and not
wounds and the majority of abdominal stab recommended in a DCS modus. The lesser sac is
wounds can be treated via selected nonoperative always to be explored to exclude injury to the
management principles of careful examination posterior gastric wall and pancreas. Indications
and repetitive clinical reassessment. Exploratory for an emergency Whipple’s procedure are scarce
laparotomies are indicated for patients with peri- and not recommended since most patients suffer-
toneal signs with or without shock [39]. Venous ing from pancreatic head injuries, in combination
(liver) bleeding, encountered during clock- or with duodenal injury, are usually in need of a
counterclockwise inspection of the four quad- DCS approach due to additional vascular inju-
rants of the peritoneal cavity, is amenable for ries. A prompt but sound assessment of the extent
packing. Arterial bleeding, such as mesenterial of gland and duct injury dictates further future
vascular injuries, cannot be packed but should be surgical management. Minor injuries without
temporary clamped and repaired or suture ligated visible duct involvement are drained. Injury to
as soon as possible. Since penetrating injuries to body and tail of the pancreas with duct laceration
the gastrointestinal tract are easily missed, espe- are treated with a distal pancreatectomy, en bloc
cially at the border of the mesenterium with the with the spleen using a linear stapler, gaining
bowel wall, both the lead surgeon and his assis- rapid control of bleeding and leakage (Fig. 26.10)
tant should “flip flop” the entire bowel with mes- [41]. Liver lacerations treated with “packing,” in
enterium from side to side to inspect the whole which six abdominal sponges should suffice, dic-
circumference. If the patient’s condition dictates tate a relook laparotomy for pack removal prefer-
staged surgery, injured bowel segments can be ably after 48 h post placement to prevent
stapled or resected and temporary tied for later rebleeding [42]. Another option for liver lacera-
definitive anastomosis during relook laparotomy. tions in a non-shocked patient, to prevent open

a b

Fig. 26.10  A penetrating injury to the tail of the pancreas swiftly controlled using a linear stapler (a) for en bloc resec-
tion of pancreas tail and spleen (b)
292 O.J.F. van Waes and M.H.J. Verhofstad

abdominal treatment, is careful placement of sev- drained and tacked for repair in relook surgery.
eral large diameter monofilament sutures using Percutaneous nephrostomy can be used as a
the figure of eight configuration to gain hemosta- bridge to definitive ureter repair. Simple intra-
sis and diminish bile leakage (Fig. 26.11). Central peritoneal bladder injuries should be repaired
retroperitoneal hematomas are in need of explo- with transurethral and/or suprapubic drainage.
ration to exclude injury to the duodenum, pan- More complex or extraperitoneal injuries receive
creas, aorta, and inferior vena cava [43]. Injury to a para-cystic drain after provisional hemostatic
the latter can be masked by a low flow state in suturing [46]. In contrast to pelvic retroperitoneal
combination with containment by the perito- hematoma caused by blunt force, hematoma by
neum, especially in through and through peri-­ gunshot or stabbing will need exploration. These
vertebral gunshot injuries. Cava injuries are haematoma are usually caused by injury to iliac
notorious for rapid exsanguination once the tam- artery, vein, or predicamentally a combination of
ponading effect of the peritoneum is released. both. Shunting, with optional fasciotomy of the
Hence it is advocated, if inferior vena cava injury lower leg, can be a limb-saving damage control
is suspected, to compress proximal and distal of strategy in these injuries. When the trajectory is
the injury onto the vertebral column by an extra suspected for injury to the rectum, a negative
assistant before opening the peritoneum. If the digital rectal examination should always be fol-
injury is not amenable for primary repair, ligation lowed by rigid rectosigmoidoscopy prior to lapa-
is an option for hemorrhage control, which will rotomy (Fig. 26.12). When blood or injury to the
be tolerated by the patient [44]. A non-expanding rectum is confirmed, pelvic sepsis should be pre-
lateral retroperitoneal hematoma does not need vented by a diverting colostomy. Injury to the
surgical exploration, unless colonic injury is sus- rectosigmoid should be assessed, during laparot-
pected. Large expanding lateral hematomas are omy, for primary repair or “bailout” diverting
most likely to be caused by kidney injury beyond colostomy and drainage [47]. Damage control
repair (AAST injury scoring scale grade 4 and 5). laparotomies should always finish with a (provi-
Nephrectomy is best performed via a lateral sional) closure of the abdominal wall wounds
approach using the dissection established by the caused by the firearm or blade, to prevent future
hematoma, after which the hilum and ureter can herniation of abdominal viscera, and a thorough
be ligated [45]. Repair of ureter injury in a DCS washout with several liters of warmed saline. In
setting is not advisable. Instead the injury can be order to protect the viscera till the subsequent

a b c

Fig. 26.11  A gunshot injury (a) to the liver. Instead of packing, large monofilament sutures in a figure of eight configu-
ration were used to treat the laceration (b, c). Thus avoiding the need for pack removal and relook surgery
26  Penetrating Injuries and Damage Control Surgery: Considerations and Treatment Options 293

a b

Fig. 26.12  Rigid rectosigmoidoscopy prior to laparotomy (a), revealing a bullet in the rectum (b)

26.6 D
 amage Control Options
for Penetrating Injuries
to the Extremities

Though the doctrine of damage control surgery

dictates “the life over limb” principle, it should
be stressed that seemingly insignificant injuries
to the extremities can be life threatening.
Junctional penetrating injuries (e.g., groin, axil-
lae) can be difficult to control since these inju-
Fig. 26.13  A temporary abdominal closure device (TAC) ries, in contrast to the more distal injuries, are not
fashioned from two percutaneous drains connected to wall suitable for temporary hemorrhage control using
suction and abdominal packs covered by adhesive plastic
sheets. A low-cost solution in patients prone for an a standard tourniquet. Not only in a prehospital
abdominal compartment syndrome or in need of relook or emergency department setting but also in the
abdominal surgery as part of DCS operation theater can hemostatic bandages or
granules and catheter balloon tamponade render
surgery and prevent an abdominal compartment provisional hemorrhage control for these injuries
syndrome, a temporary abdominal closure device in which rapid access for vascular control is dif-
can be fashioned from a combination of (adhe- ficult [49, 50]. As mentioned prior, the surgeon
sive) plastic sheets, gauze, and percutaneous should be familiarized with shunt options to
drains connected to a suction device (Fig. 26.13) bridge vascular injuries. Most vascular injuries
as a (cheaper) alternative to commercial negative due to stabbing or projectiles are not fit for pri-
pressure wound therapy [48]. mary repair and thus will need an interposition
294 O.J.F. van Waes and M.H.J. Verhofstad

a b

Fig. 26.14  A gunshot injury to the left upper extremity (a) with a concomitant fracture of the humerus (b). In DCS
treated with a shunt for the brachial artery injury (c) and external fixator (d)

graft. Patients in need of DCS are not in the con- distal flow. This is followed by placement of an
dition to undergo the lengthy procedure of gain- external fixator, in case of a fracture (Fig. 26.14).
ing proximal and distal vascular control followed Prophylactic fasciotomy of the affected limb is
by harvesting and preparing a vein graft, which highly advocated, prior to definitive repair or
can then be sutured into the defect. A more real- when using a shunt in a DCS case [51, 52].
istic scenario is a patient with multiple penetrat-
ing injuries in need of DCS. When confronted Conclusion
with a penetrating injury to the extremities with a Patients with penetrating injuries can present
vascular deficit, it is more than likely to be themselves to any emergency department.
accompanied with a fracture and nervous injury. Hence all trauma care providers should be
The latter can be tagged with 5:0 monofilament familiar with the injury patterns (HET versus
suture for later definitive repair. The most practi- LET) and treatment options. Hemorrhage con-
cal approach to these combined injuries is to gain trol techniques used in prehospital or emer-
vascular control and shunt the defect to preserve gency department settings (e.g., hemostatic
26  Penetrating Injuries and Damage Control Surgery: Considerations and Treatment Options 295

agents and catheter balloon tamponade) can improved radiopaque marker system for delineating
be used as “bailout” options in theater as well. the path of penetrating injuries. J Trauma.
2005;58:1078–81.
When DCS is needed, it is advised to return 12. Brook A, Bowley DMG, Boffard KD. Bullet mark-
the patient to theater for definitive repair as ers – a simple technique to assist in the evaluation of
soon as the preset resuscitation values are penetrating trauma. J R Army Med Corps.
established to avoid the detrimental effects of 2002;148:259–61.
13. Bell RS, Mossop CM, Dirks MS, Stephens FL,

missed injury for which this patient group is Mulligan L, Ecker R, et al. Early decompressive cra-
prone. niectomy from severe penetrating and closed head
injury during wartime. Neurosurg Focus.
2010;28(5):EI.
14. Rosenfeld JV, Bell RS, Armonda R. Current concepts
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PA, Nicol AJ, Vermeulen J. Management of penetrat- management of complex pancreatic injuries. S Afr
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 Complications After Damage
Control Surgery: Pin-Tract
27
Infection

Peter V. Giannoudis and Paul Harwood

27.1 Introduction regarding life-threatening physiologic distur-

bances have passed. This can be termed sys-
Damage control is an approach to care for patients temic damage control. Moreover, it has been
in extremis [1]. The primary aim is to avoid wors- recognised lately that immediate definitive
ening the patient’s situation by only undertaking care of complex isolated extremity injury may
interventions in the acute phase that are life or also be inappropriate (Fig. 27.1) [6–8]. Large
limb saving. Complex, prolonged or specifically incisions and internal fixation in swollen, com-
risky or immune stimulatory procedures are promised or violated soft tissues have been
avoided. The patient then undergoes staged associated with an excess of wound and infec-
reconstruction once their physiology has suffi- tive complications [9, 10]. Examples include
ciently recovered for them to withstand this. As open and complex periarticular injuries, par-
regards to orthopaedic surgery, this usually ticularly in the lower limb [11]. It is often sen-
involves the initial application of spanning exter- sible to temporarily impart secure skeletal
nal fixation to rapidly stabilise skeletal injuries stabilisation using an external fixator in such
[2–4]. Intramedullary nailing has particularly situations in order to allow the soft tissue
been associated with immune stimulation and swelling to subside and any open injuries to be
systemic complications [5]. The patient then treated prior to definitive fixation. Furthermore,
undergoes further definitive procedures at an such injuries are increasingly being treated in
appropriate time point once initial concerns expert centres by specialists. This means that
temporary stabilisation may be relevant in cer-
tain situations where it would not otherwise be
required, allowing safe transfer to facilities
P.V. Giannoudis, MD, FACS, FRCS (Glasg and Eng) where appropriately skilled personnel and
Academic Department of Trauma & Orthopaedics,
equipment are available. This is termed local
School of Medicine, University of Leeds & NIHR
Leeds Biomedical Research Unit, Chapel Allerton damage control.
Hospital, LS7 4SA Leeds, West Yorkshire, A major consideration when utilising tempo-
Leeds, UK rary external fixation is pin-site care and infec-
e-mail: p.giannoudis@leeds.ac.uk
tion. Particularly where patients are to undergo
P. Harwood, MB, ChB, MSc (Dist), FRCS (T&O) (*) definitive internal fixation, violation and poten-
Academic Department of Trauma & Orthopaedics,
tial bacterial contamination of the soft tissue
School of Medicine, University of Leeds & Leeds
General Infirmary, Leeds, West Yorkshire, UK envelope raise concerns regarding subsequent
e-mail: pauljharwood@me.com deep infective complications which are a major

© Springer International Publishing AG 2017 297

H.-C. Pape et al. (eds.), Damage Control Management in the Polytrauma Patient,
DOI 10.1007/978-3-319-52429-0_27
298 P.V. Giannoudis and P. Harwood

Fig. 27.1  Male patient 26 years of age that sustained a right floating knee injury which was initially managed with
external fixators applied to the ipsilateral femoral and tibial fracture

source of morbidity and extremely expensive to excess of deep infective complications following
treat. Here we review current evidence regarding such an approach, the presence of external fixa-
pin-site care in damage control orthopaedics, tion pin sites logically must introduce the poten-
infection rates following such procedures and tial for this to occur. It is therefore important that
practices which may help reduce such problems. these decisions are not taken lightly, and external
Indications and effectiveness are explored fixators are only applied where they provide true
elsewhere. benefit. Counterargument to this is that when
Whilst specific literature on damage control applied carefully, this approach is safe and
applications of external fixation exist, it is impor- reduces the risk of more serious, potentially life-­
tant to note that much of the evidence and knowl- threatening complications. It is important that the
edge on pin-site care and infection are based on balance of risk versus benefit is carefully and
experience from definitive external fixation individually assessed. The level of concern is
including fine wires. In the absence of other related to the planned definitive fixation method.
sources of information, it is reasonable to apply If the injury is to be managed by internal fixation,
such findings to this practice, but it is appropriate particularly intramedullary nailing, more careful
to consider that important differences apply, not consideration is required. There has perhaps been
least the nature of the fine wire/tissue interface in a tendency to adopt a systemic damage control
comparison with more rigid half pins and the approach too readily at times, and this has been a
length of time that the fixators are applied. source of criticism of the technique [12, 13].
Clearly these decisions must be taken individu-
ally and the indications for systemic damage con-
27.2 I ndications for Damage trol applied with caution. Regarding local damage
Control control, the literature would tend to support that
early definitive internal fixation in a limb where
In attempting to avoid infective complications the soft tissues are suboptimal leads to an increase
when using external fixation for damage control, in wound and infective complications compared
certain precautions should be taken from the out- with a period of immobilisation to allow soft tis-
set. A fundamental aspect of this is applying the sue care [6, 10, 11]. Whether this can be achieved
indications for damage control correctly [12]. by plaster immobilisation should be carefully
Whilst various studies have identified little or no considered but, particularly in the lower limb and
27  Complications After Damage Control Surgery: Pin-Tract Infection 299

absolutely where the soft tissue envelope is applied unstable fixator may represent more of a
breached or severely compromised, it is the risk than no fixator at all. Even this is relative
author’s experience that thoughtfully applied however, no temporary fixator will afford abso-
external fixation is almost always preferable in lute stability, and at times the user may elect to
unstable injury patterns. This provides much accept a degree of instability in order to fulfil one
more stable immobilisation, is usually more of the following priorities. This is however a dif-
comfortable for the patient, allows easy access to ficult judgement call, and the balance of these
soft tissues for care and inspection and usually competing interests must be carefully considered
helps to provisionally reduce fractures, making in each case. It is generally recommended to
definitive fixation more straightforward. avoid inserting pins through traumatised tissue –
Similarly, it has been demonstrated that manage- the zone of injury. Certainly placing pins in open
ment of complex injury by non-specialists with- fracture sites is not advised unless absolutely no
out adequate imaging, planning or equipment other option exists. To avoid violating closed soft
will lead to an increase in complications and poor tissue injuries is a more relative recommenda-
outcome, including infection. It is therefore rea- tion, though such pins likely are at increased risk
sonable to adopt such an approach to allow treat- of infection. If the pin is inserted in areas of soft
ment to be planned and patients transferred where tissue stripping and closed (or open) degloving,
necessary to appropriate facilities [14]. these pins will effectively be in communication
with the fracture site and associated haematoma.
If such pins become infected, this can result in
27.3 Considerations serious complication and would likely be a very
in Application of Spanning significant risk if conversion to internal fixation
External Fixation were planned. Less severely injured tissues pres-
for Damage Control ent a more relative problem and, whilst it is
always preferable to place pins through normal
Steps can be taken when applying the external tissues, if this results in a situation where a stable
fixator to reduce the risk of serious infective com- construct cannot be constructed then ongoing
plication. Careful technique is critical, and poten- injury due to fracture site motion may well
tially minor problems can quickly escalate into increase the risk of infection on conversion to
serious complications. internal fixation more than placing the pins
through damaged tissue. Pin placement through
areas of compromised soft tissue is at times inev-
27.3.1 Priorities When Placing Pins itable to impart stability in severe injury. Placing
pins outside the zone of proposed fixation is a
The process of applying stable external fixation is more debatable aspiration. In some situations, for
well described elsewhere [15]. There are specific example where intramedullary fixation is
considerations when considering the risk of planned, this is not possible as the nail effectively
infection following subsequent conversion to has a zone of fixation that traverses the entire
definitive fixation. It is useful to think of the com- bone. In fractures to be treated by plating the area
peting priorities in pin placement when applying where the plate will lie, particularly in the line of
such fixators in these terms. One should remem- planned incision, should logically be
ber at all times that these factors are relative; the avoided where possible. The evidence supporting
need to comply with anatomic constraints and this is however contradictory, with some studies
avoid injuring critical neurovascular structures finding an increased rate of deep infection in such
during pin insertion remains paramount. situations whilst others do not [16, 17]. These are
Imparting stability to the construct is usually the however relatively small retrospective studies,
next priority; without this, the act of applying the and negative results may be subject to type II
fixator becomes futile, and indeed, a poorly sampling error and selection bias. It makes
300 P.V. Giannoudis and P. Harwood

l­ogical sense that placing pins where internal imperative that pins are inserted carefully to cre-
fixation will lie should increase risk of infection. ate a stable pin-bone interface. Pre-drilling to
The question is to what degree this is a problem. create a pilot hole followed by manual pin inser-
Compromising pin placement to avoid the zone tion is recommended. Secure bi-cortical purchase
of fixation may render the construct so unstable should be achieved and checked radiographically
that the effect of ongoing motion on soft tissue and the stability of the pin checked manually
swelling and recovery might well outweigh any directly after insertion. If the pin is not com-
perceived advantage and actually make the risk pletely stable, it should be resited. Haematoma
of infection higher. Construct design in such formation at pin sites results in a very effective
cases needs careful consideration; a conscious potential culture medium with a portal for inocu-
effort should be made to place pins outside the lation. It is advisable to carefully clean the pin
zone of fixation where possible. immediately following insertion and apply a
Where definitive external fixation is planned, dressing with a clip or bung to hold this in place
final construct design still needs to be considered to minimise this. If these become soiled, they
during pin placement though this is less of a con- should be changed at the end of the procedure.
cern. Deep infection in pin sites can become a During fracture manipulation to achieve reduc-
problem even in the absence of internal fixation, tion, tissue tensions can change. It is therefore
and therefore sensible steps should always be important to carefully check each pin again at the
taken to minimise this risk. It is also sensible to end of the procedure and further release any soft
avoid pin insertion in areas where definitive tissues as appropriate.
external fixation will ultimately be placed, as
infection with resultant soft tissue and bone dam-
age here may compromise this. This is even more 27.3.3 Stability
important in complex cases where corticotomy
for bone transport might be required and careful Ongoing motion of injured tissues, particularly
consideration to the placement of external pin at the fracture site, causes pain and leads to
must be given in these situations. Furthermore, it ongoing tissue trauma. This can result in persis-
is sometimes helpful to leave the temporary fix- tent or increasing swelling and blistering and in
ator in place whilst applying definitive fixation, patients with external fixation pins in place will
particularly with complex injury patterns and potentially increase the risk of pin-site infection
articular injuries. Thoughtful fixator construction due to motion of the tissues around the pin. As
is required to facilitate this. highlighted above, it is therefore pertinent to
afford as much stability as possible to the injured
limb segment when applying external fixation in
27.3.2 Pin Insertion Technique such circumstances. Placing pins appropriately
and prioritising stability are discussed above
Meticulous surgical technique can help minimise and summarised elsewhere. It is important to
soft tissue damage and ultimately reduce the risk critically assess construct stability following
of infection. This is described elsewhere [15]. In fixator application. This can be improved by
terms of reducing the risk of pin-site infection, adding fixation, improving working length
the main emphasis is protection of the soft tissues (termed near-far pin arrangement), spanning
by careful placement of incisions, blunt dissec- joints with small periarticular fragments and
tion and appropriate skin release to reduce pres- altering arrangements of rods and bars. It is
sure effects. Care should be taken during drilling therefore critical that surgeons applying damage
and pin insertion to protect soft tissues to prevent control external fixators are well versed in the
mechanical and thermal damage. Unstable pins principles of building stable constructs and
lead to a great increase in infection rates and add understand the basic mechanics which contrib-
nothing to construct mechanics. It is therefore ute to this [15].
27  Complications After Damage Control Surgery: Pin-Tract Infection 301

27.4 Pin-Site Care these circumstances, dressing should be

changed when there is strikethrough.
Limited objective evidence regarding different • A non-shedding material should be used to
pin-site care regimens is available. The majority clean the pin sites with chlorhexidine in alco-
relates to the care of pin sites for definitive rather hol. If this is contraindicated or the patient
than temporary fixators. The objective, to mini- develops sensitivity, then saline should be used.
mise the risk of infection, remains the same in • Patients should keep pin sites dry and never
either scenario. The principles are identical and immerse them in order to bathe but may
to use the same approach is logical. A Cochrane shower immediately before dressings are
review in 2013 concluded that there was insuffi- changed (once a week).
cient evidence to recommend pin-site care strat-
egy to minimise infection rates and what did exist The publication relates specifically to the care of
was of generally poor quality [18]. The authors patients with definitive care fixators. Important dif-
recommended that further clinical studies were ferences exist between these and the type of tempo-
undertaken to help answer this question. A more rary devices under discussion here. Probably most
recent literature review reached the same conclu- important is overall stability – definitive construct
sion [19]. will usually be much more rigid as most are
In the absence of robust evidence on pin-site designed to allow motion and weight-bearing – and
management, an expert group in the United for this reason will have many more pin-tissue inter-
Kingdom met in 2010 to form a consensus state- faces. They will be in place for much longer periods
ment to help guide care [20]. They recommend than damage control fixators, and there is usually no
the following: intention to replace the fixator with internal
implants, and therefore the potential consequences
• Sterile non-shedding dressings should be used of minor pin-site infections are less. Advice regard-
to keep pin sites covered at all times ing showering is also probably not appropriate for
(Fig.  27.2). These should be of a type that those with damage control fixators.
draws exudate away from the wound.
• Gentle compression should be applied to the
dressing using a bung or clip. 27.5 Diagnosis and  Treatment
• First dressing change should be carried out of Pin-Site Infection
between 1 and 3 days post-operatively.
• Pin sites should then be cleaned and dressings Definitive diagnosis of pin-site infection can be
changed every 7 days unless there is excessive troublesome and is on the whole reliant on clini-
discharge or infection is suspected. Under cal signs and symptoms. In general, culture swabs

a b

Fig. 27.2  Female patient sustained an open book pelvic definitive care. (a)The skin around the iliac crest pin sites
ring injury which was initially stabilised with a Hoffman looks inflamed. (b) There is also discharge of pus
II external fixator and was transferred to our institution for
302 P.V. Giannoudis and P. Harwood

should be relieved; this may require skin release

at the pin sites once the infection has settled
which can usually be achieved using local anaes-
thetic. Soft tissue motion around pin sites is a fre-
quent cause of infection; if the construct is
unstable or pins are close to joints, it may be that
revision is required to improve this, possibly
spanning adjacent joints. If this does not address
the issue, then pins should be removed and res-
ited. If infection is serious or recurrent, then seri-
Fig. 27.3  A Hoffman II external fixator was applied in a
male patient with an open book pelvic ring injury for tem- ous consideration should be given to the safety of
porarily stabilisation. The pin sites are covered with proceeding with exchange to definitive fixation,
Allevyn dressing as per our unit’s protocol and this should certainly be delayed until the
infection has been treated. It may be that the
are not helpful as any external fixator pin will rap- injury is suitable for treatment with definitive
idly become contaminated and not only will a external fixation, which would likely be safer
positive result not be diagnostic of infection but under such circumstances. Some studies have
the cultured bacteria from the pin may well not be failed to find correlation between previously clin-
representative of any organism causing an infec- ically infected pin sites and late deep infection
tion. Previous studies in damage control patients [24, 25]. Others have found a strong link between
found that rates of positive culture from fixator cases where pin sites became infected prior to
pins increased rapidly the longer a fixator was in exchange and subsequent deep infective compli-
place but that there was no correlation between cations [26–28]. This body of literature is diffi-
positive results and subsequent infective compli- cult to interpret and the numbers are relatively
cations [21]. Infection should be diagnosed based small, and therefore subgroup analysis examin-
on the presence of increasing pain at a pin site, ing only those in the external fixation groups who
decreased tolerance of limb segment motion, suffered pin-site infections is even smaller and
spreading redness, increased swelling and dis- prone to error. The studies are heterogeneous and
charge (Fig. 27.3) [20]. It is important to note that on the main retrospective with divergent inclu-
not all infected pin sites will discharge and not all sion criteria, making grouped interpretation very
discharging pin sites are infected. Serous dis- troublesome. Authors in some studies did not
charge in the absence of other signs of infection is advocate exchange in patients with previously
usually inflammatory in nature; purulent dis- infected pin sites at all or removed the fixator for
charge is more indicative of infection. Various a period prior to the secondary procedure [2, 29,
systems have been proposed in an attempt to stan- 30]. Another excluded patients with infected pin
dardise this clinical approach to diagnosis, and sites from analysis [31]. It is clear that each case
these may have some utility in clinical practice must be taken on its merits and great care taken in
but on the whole are used for research purposes decision-making with patients who do suffer pin-­
[22, 23]. Diagnosis is therefore based on classical site infection.
signs of infection as outlined above.
In general, pin-site infections have been found
to be effectively treated by increased frequency 27.6 Exchange from  Temporary
of pin-site care, relief of any predisposing factors to Definitive Fixation
and oral antibiotics. Spreading infection or signs and Results
of systemic infection should prompt investigation
for other sources or local collections. The pins Decision-making around exchange to definitive
and overall construct should be critically fixation is critical if the advantages of adopting
assessed. Any causes of soft tissue pressure this approach are to be realised. The definitive
27  Complications After Damage Control Surgery: Pin-Tract Infection 303

fixation method should be chosen as appropriate, fracture in whom definitive intramedullary nail-
not just for the bony injury in question, but taking ing was planned might be better served by plate
into account the patients systemic status, soft tis- or Ilizarov fixation in order to move the implants
sue envelope and the presence and state of the out of the zone of fixation if the proximal pin
spanning external fixator. It may be, for example, sites have been recurrently infected and the plate
that an injury which in other circumstances might would involve these.
be best treated by intramedullary nailing would Table 27.1 summarises infective outcomes
be better treated using a circular frame in a patient and timing of exchange from external to internal
who has been critically ill in intensive care fol- fixation in major publications on systemic and
lowing multiple injuries with an external fixator local damage control. These studies are extremely
in place for 6 weeks. A patient with a distal tibial diverse, and this is reflected in the variability of

Table 27.1  Summary of results from published studies reporting results of local and systemic damage control
Type of
damage Infection
Study Date control Patients/fractures N rate (%) Exchange time (days)
Van den Bossche [7] 1995 Systemic Open femoral fracture 16 0.0 Mean 21
and local
Yokoyama et al. [27] 2008 Systemic Open tibial fractures 21 13 18.3 (planned), 52.1
and local (non-union in ex-fix)
Mody et al. [32] 2009 Systemic Polytrauma, tibia/femur 58 40.0 Median 9 (4–414)
and local All battlefield injuries
Suzuki et al. [33] 2010 Systemic Polytrauma, humerus 17 11.8 Mean 6.2 (2–14)
and local
Nowotarski et al. [2] 2000 Systemic Femur, polytrauma 59 1.8 7–49
Scalea et al. [3] 2000 Systemic Femur, polytrauma 43 2.9 Mean 4, IQR 2–6
Taeger et al. [34] 2005 Systemic Polytrauma 101 7.0 Mean 13.7, 3–46
49 femur, 39 tibia, 25
pelvis, 22 upper limb
Harwood et al. [21] 2006 Systemic Polytrauma, femur 111 7.2 Mean 14, 1–61
Lavini et al. [30] 2007 Systemic Polytrauma, femur 39 5.1 Group A – 5.6/7 (4–7)
Group B – 4-6/12 – ex-fix
removed – MRI/WC scan
Group 3 – treated with EF
Stojiljkovic et al. [35] 2008 Systemic Polytrauma, femur 24 5.5 Only 6 converted – 16 %
of these infected
Mathieu et al. [29] 2011 Systemic Polytrauma, long 16 6.3 Mean 84 (60–90)
bones, pelvis
Metsemakers et al. [36] 2015 Systemic Polytrauma, femur 87 0.0 5–15
Maurer et al. [26] 1989 Local Open tibial fracture 24 29.2 Mean 52 (3–360)
Sirkin et al. [6] 2004 Local Tibial pilon 56 5.4 Mean 12.7
Barei et al. [10] 2004 Local Tibial plateau 83 8.4 Mean 9
Egol et al. [11] 2005 Local Tibial plateau 49 6.1
Yokoyama et al. [25] 2006 Local Open tibial fracture 42 16.7 Mean 52.4 (2–135) and
114 (60–240)
Parekh et al. [37] 2008 Local Tibia (36)/femur (16) 47 16.0 Mean 5 (1–23)
Oh et al. [38] 2011 Local Periarticular lower limb 59 3.4 Mean 15.3 (4–81)
Laible et al. [16] 2012 Local Tibial plateau 79 7.6
Japjec et al. [39] 2013 Local Tibial pilon 15 0.0 Mean 7
Roussignol et al. [31] 2014 Local Tibial fracture 55 7.3 Mean 64 (14–365)
Shah et al. [17] 2014 Local Tibial pilon (97)/ 182 13.7 Mean 20 (2–156)
plateau (85)
304 P.V. Giannoudis and P. Harwood

their reported outcomes . Some include only or a fixation was only applied if the fracture failed to
very high proportion of open fractures. In others, unite in the external fixator. Few studies have
the external fixators were left in place for very specifically addressed the timing of exchange
long periods in some patients. There are high pro- specifically, and no randomised studies exist.
portions of multiply injured patients. Despite Given the individualised decision-making that is
this, the majority report results with infection required in these patients, a study randomising
rates of less than 10% which is very reasonable in the timing of exchange would be very difficult to
that context. Those with high infection rates usu- design ethically. Harwood et al. examined a
ally have a peculiarity in design which explains group of polytrauma patients with femoral shaft
this. For example, the study by Mody et al. con- fracture treated either by primary intramedullary
tains exclusively battlefield casualties with a very nailing (81 fractures) or initial damage control
high proportion of open blast injuries [32]. This (111 fractures) followed by staged internal fixa-
factor was highly associated with deep infection, tion [21]. The mean time of exchange procedure
and despite this, overall results were good. was 14 days (range of 1–61). Despite the fact that
Studies by Maurer and Yokoyama contain only the damage control group had more severe inju-
high-grade open fractures and include patients in ries, overall there were no significant differences
whom the external fixators were left in place for in deep infection rates, with 7.2% in the damage
extremely long periods; in some of these the control group and 6.2% in the primary nailing
intention was to treat by external fixation defini- group. Further examination of the data found that
tively, the exchange only occurring when the whilst more patients had positive microbiology
fracture failed to unite [25, 26]. swabs for contaminated pin sites if external fix-
Determining the optimum time for exchange ators were in place for more than 14 days, this did
requires balance of the competing advantages of not result in higher rates of clinically important
early exchange to reduce the risk of pin sites infection in these patients. It would seem likely
becoming contaminated against delaying that this simply represented the fact that there
exchange whilst the patient’s systemic physiol- was more time to send swabs in patients with
ogy and local soft tissues recover. Clearly patients external fixators in place for longer, given that no
should never be placed at undue risk of life-­ specific protocol for timing of microbiological
threatening complication by undertaking com- testing was employed. A multivariate analysis
plex secondary surgery too soon. Similarly, controlling for other factors did however reveal a
performing definitive internal fixation in a local weak association between external fixation for
damage control situation before the soft tissues more than 14 days and infective complications.
have adequately recovered will likely increase Other studies have examined infection rates
the risk of infection more than waiting in the based upon the time between external fixator
presence of external fixation pins. It is therefore application and exchange to internal fixation. The
generally recommended to perform definitive majority found no relationship between these
surgery as early as possible provided that the variables [6, 16, 24–26, 31, 37]. Only a few stud-
patient’s systemic state and soft tissues have ade- ies have found a positive relationship between
quately recovered. It is important to be critical in duration of fixation and subsequent deep infec-
this decision-making and avoid performing sec- tion [27]. In interpreting these results, it is impor-
ondary surgery too early for convenience’s sake. tant to consider the limitations of the studies in
Evidence regarding the timing of exchange this outcome. The decision on when to exchange
and risk of infection is difficult to interpret. in these studies was almost certainly taken indi-
Whilst a number of studies examining such vidually in each case, based on previous experi-
patient groups have been published, these are ence. Furthermore, various protocols were
very diverse and retrospective in nature. Some employed, including opting for definitive exter-
series have patients in whom the external fixators nal fixation in high-risk patients and excluding
were in place for many months. In some, internal patients from the studies with infected pin sites.
27  Complications After Damage Control Surgery: Pin-Tract Infection 305

Some authors have advocated use of specific cri- tage and/or excision of the pin sites. Protocols
teria to determine whether exchange is appropri- have been described though these are not based
ate including the absence of clinical infection, the on specific evidence; an example is detailed as
absence of previously infected pin sites, normal follows [21]:
inflammatory markers and no evidence of infec-
tion on MRI or radio-labelled nuclear medicine 1. The external fixator is removed in the anaes-
examinations [26, 30, 31]. Our group have not thetic room:
found these investigations to be routinely neces- (a) External fixator rods and clamps are
sary, preferring instead to exchange in a short removed leaving only the pins in place.
time frame, as soon as the patient has physiologi- (b) These are prepped and removed under

cally recovered, where possible within 2 weeks. aseptic conditions.
In selected cases, where the patient’s local or sys- (c) Pin tracks are excised to subcutaneous fat
temic physiology is felt insufficiently improved and superficially irrigated with sterile
within this time frame, such an approach might saline; avoid introducing this under pres-
be helpful. It may be that in these situations an sure driving potential contaminants
alternate definitive fixation method should be deeper.
employed as detailed above. (d) Some surgeons choose to leave pin sites
Overall, it would therefore seem logical to open, covering these with waterproof
undertake exchange from temporary to definitive sterile dressings at this stage and leaving
fixation as soon as is possible within constraints these in place during the definitive sur-
detailed elsewhere. When this is delayed, very gery, prepping over them.
careful consideration should be given to the cho- (e) Some surgeons choose to close pin sites
sen mode of fixation. following excision, potentially at this stage
or following the definitive procedure.
2. The patient is taken into theatre and then com-
27.7 Technique for Exchange pletely re-draped; all previously used surgical
equipment is discarded:
Various methods of exchange have been (a) Surgical team re-scrub and re-gown.
described. Whilst it may occasionally seem (b) Some surgeons choose to over-drill pin
advisable to remove the fixator for a period prior sites, either at first or second prep, partic-
to secondary procedures and give the external ularly when the fixator has been in place
fixation pin sites time to heal, on the whole this is for more than 14 days.
not advocated. In most cases, this would remove (c) Surgery is undertaken in a standard man-
many of the benefits of adopting a damage con- ner; incisions should be placed away from
trol approach approach in the first place. The soft previous pin sites.
tissues are usually better served by the stability of
a correctly applied external fixator rather than In a study of patients treated for tibial frac-
removing this and applying a splint. This also ture with local damage control, Rossignol et al.
facilitates ongoing inspection and treatment of reported results after sending reaming debris
the soft tissues. As detailed above, it is usually for culture in every case. Twenty-two percent of
better to revise the fixator to render it more stable these samples were positive on microbiological
and move offending pins rather than remove the culture; none of these patients, who received
fixator entirely. Clinical results suggest that very targeted antibiotics for 6–8 weeks, went on to
acceptable rates of infective complication can be develop deep infection following intramedul-
achieved using such an approach. lary nailing. This would seem a reasonable
Most authors advocate removal of the fixator approach, though it is not possible to comment
in the operating theatre following anaesthesia, upon whether it prevented clinical infection in
immediately before internal fixation with curet- this study.
306 P.V. Giannoudis and P. Harwood

Conclusions 5. Pape HC, Grimme K, Van Griensven M, et al. Impact

of intramedullary instrumentation versus damage
Damage control external fixation requires
control for femoral fractures on immunoinflammatory
careful decision-making and meticulous plan- parameters: prospective randomized analysis by the
ning from the outset. This may be challenging EPOFF Study Group. J Trauma. 2003;55(1):7–13.
in the context of major trauma. Consideration 6. Sirkin M, Sanders R, DiPasquale T, et al. A staged
protocol for soft tissue management in the treatment
of the likely definitive treatment method is
of complex pilon fractures. J Orthop Trauma.
important in deciding on pin placement. 2004;18(8 Suppl):S32–8.
Surgeons involved in such cases should have a 7. Van den Bossche MR, Broos PL, Rommens PM. Open
good understanding and experience of mono- fractures of the femoral shaft, treated with osteosyn-
thesis or temporary external fixation. Injury. 1995;
lateral external fixation techniques in order to
26(5):323–5.
allow versatility in frame application and 8. Haidukewych GJ. Temporary external fixation for the
appropriate surgical technique. Pin-site care management of complex intra- and periarticular frac-
should begin during pin insertion and be care- tures of the lower extremity. J Orthop Trauma.
2002;16(9):678–85.
fully maintained until exchange to definitive
9. Blauth M, Bastian L, Krettek C, et al. Surgical options
fixation. Pin-site infections should be aggres- for the treatment of severe tibial pilon fractures: a
sively treated and the fixator examined for study of three techniques. J Orthop Trauma. 2001;
problems, particularly instability, and revised 15(3):153–60.
10. Barei DP, Nork SE, Mills WJ, et al. Complications
as necessary. Exchange procedures should be
associated with internal fixation of high-energy bicon-
undertaken as soon as the patient is ready, dylar tibial plateau fractures utilizing a two-incision
within 2 weeks if possible. Evidence on tim- technique. J Orthop Trauma. 2004;18(10):649–57.
ing of exchange does not however appear to 11. Egol KA, Tejwani NC, Capla EL, et al. Staged man-
agement of high-energy proximal tibia fractures (OTA
demonstrate a large increase in the risk of
types 41): the results of a prospective, standardized
deep infection if exchange is undertaken after protocol. J Orthop Trauma. 2005;19(7):448–455; dis-
this period. Careful individual decision-mak- cussion 56.
ing is critical in these patients if infective 12. Pape HC, Tornetta 3rd P, Tarkin I, et al. Timing of
fracture fixation in multitrauma patients: the role of
complications are to be minimised. If doubts
early total care and damage control surgery. J Am
remain about the suitability of a patient’s soft Acad Orthop Surg. 2009;17(9):541–9.
tissues for internal fixation, alternative meth- 13. Pape HC, Pfeifer R. Safe definitive orthopaedic sur-
ods including definitive external fixation gery (SDS): repeated assessment for tapered applica-
tion of Early Definitive Care and Damage Control?:
should be considered.
an inclusive view of recent advances in polytrauma
management. Injury. 2015;46(1):1–3.
14. Nanchahal J. Standards for the management of open
fractures of the lower limb. London: Royal Society of
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3. Scalea TM, Boswell SA, Scott JD, et al. External fixa- plates overlapping provisional external fixator pin
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21. discussion 21–3 for preventing infections associated with external
4. Harwood PJ, Giannoudis PV, van Griensven M, et al. bone fixators and pins. Cochrane Database Syst Rev.
Alterations in the systemic inflammatory response 2013;12
after early total care and damage control procedures 19. Ktistakis I, Guerado E, Giannoudis PV. Pin-site care:
for femoral shaft fracture in severely injured patients. can we reduce the incidence of infections? Injury.
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20. Timms A, Vincent M, Santy-Tomlinson J, et al. A trauma soldiers. Orthop Traumatol Surg Res. 2011;
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21. Harwood PJ, Giannoudis PV, Probst C, et al. The risk osteosynthesis after external fixation in multiple-­
of local infective complications after damage control trauma patients. Strateg Trauma Limb Reconstr. 2007;
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22. Clint SA, Eastwood DM, Chasseaud M, et al. The nailing after external fixation for tibial shaft fracture:
“Good, Bad and Ugly” pin site grading system: a reli- risk factors for union and infection. A 55 case series.
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24. Yokoyama K, Itoman M, Shindo M, et al. Deep infec- 34. Taeger G, Ruchholtz S, Waydhas C, et al. Damage
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tures. Orthopedics. 1999;22(5):485–90. 59(2):409–16. discussion 17
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Indian J Orthop. 2008;42(4):410–9. 38. Oh JK, Hwang JH, Sahu D, et al. Complication rate
28. Tornetta 3rd P, DeMarco C. Intramedullary nailing and pitfalls of temporary bridging external fixator in
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 Complications Status Post Damage
Control for the General Surgeon
28
Anastasia Kunac and David H. Livingston

28.1 Damage Control use of non-­warfarin anticoagulants, many with

for the General Surgeon no or complicated reversal agents, is increas-
ingly encountered in patients with emergent sur-
Damage control laparotomy is widely practiced gical conditions, the need for damage control
as a temporizing measure to salvage surgical for uncontrolled coagulopathy will not be an
patients whose physiologic derangements do uncommon event.
not permit the completion of an intended opera- The term “damage control laparotomy” was
tion. The more complete description of the coined by Rotondo et al. in 1993 who reported a
development and evaluation of damage control salvage rate of greater than 70% in patients with
laparotomy following severe trauma is outlined major abdominal vascular injuries and concomi-
in Chaps. 1 and 2. However, it is worth briefly tant shock, acidosis, and hypothermia. This
reviewing the genesis of the procedure in light lethal triad of core temperature <35 °C, disrup-
of developing of early and late complications. tion of hemostatic mechanisms, and metabolic
The technique was popularized in the early acidosis as a marker of impaired oxygen delivery
1980s by Stone and associates for surgical treat- may occur not only from hemorrhagic shock in
ment of coagulopathic trauma patients. Stone the setting of acute traumatic injury but most
described the technique of packing, control of certainly can apply to general surgery patients
hemorrhage, bowel resection without anastomo- suffering from profound shock whether the
sis or stoma formation to control contamination, source is hemorrhage or sepsis. The concept of
and biliary or pancreatic drainage if necessary. abbreviated laparotomy or “damage control” in
Patients returned to the operating room for critically ill general surgery was first supported
definitive operative repair of injuries following in a study by Finlay et al. in 2004. Finlay demon-
correction of coagulopathy. As the widespread strates a lower than expected mortality rate for
surgical conditions such as peritonitis, infarcted
bowel, severe pancreatitis, ruptured abdominal
A. Kunac, MD, FACS aortic aneurysm, and postoperative/post-proce-
Rutgers-New Jersey Medical School, dural hemorrhage. The observed mortality rate
Newark, NJ, USA
was 7% utilizing damage control techniques, as
D.H. Livingston, MD, FACS (*) compared to predicted 50–65% mortality utiliz-
Rutgers-New Jersey Medical School,
ing the Physiological and Operative Severity
University Hospital, M234,
150 Bergen Street, Newark, NJ 07103, USA Score for enumeration of Mortality and morbid-
e-mail: livingst@njms.rutgers.edu ity (POSSUM) scoring system.

© Springer International Publishing AG 2017 309

H.-C. Pape et al. (eds.), Damage Control Management in the Polytrauma Patient,
DOI 10.1007/978-3-319-52429-0_28
310 A. Kunac and D.H. Livingston

As more general surgeons are employing few studies have looked at the pitfalls of dam-
use of the open abdomen, additional literature age control techniques. This chapter will focus
is available to describe when these techniques on complications post damage control as they
should be applied and what the anticipated pertain to the general surgeon.
complications may be. A recent prospective
observational study by Bruns et al. describes
indications for nontrauma open abdomens in 28.2 Intra-abdominal
338 patients with abdominal pathology man- Hypertension
aged by general surgeons with laparotomies and Abdominal
performed over 1 year (June 2013–June 2014). Compartment Syndrome
Bruns describes demographics, surgical site
complications, and mortality in these patients. Perhaps the most common reason for which a
The patient population included primary lapa- general surgeon might utilize damage control
rotomies performed by the acute care emer- laparotomy is profound intra-abdominal sepsis
gency surgery team, and in this patient with or without septic shock. Under such cir-
population, 28% were left with open abdo- cumstances, the focus would be source control
mens. Indications included “damage control” followed by restoration of normal physiologic
(acidosis, coagulopathy, or hypothermia), and homeostatic parameters with consideration
planned second look, excessive contamination, given to blood and fluid resuscitation. Particularly
decompression, and combinations of the afore- when fluid resuscitation is substantial, develop-
mentioned. Common complications include ment of primary or secondary abdominal com-
surgical site infection (14%), fascial dehis- partment syndrome is possible. Primary
cence (10%), and fistula formation (10%). The abdominal compartment syndrome (ACS) can
in-­hospital mortality of patients with an open occur in the preoperative or pre-intervention
abdomen was 30% indicating the severity of time period where the patient is undergoing
illness and physiologic derangements and aggressive fluid resuscitation. Hypotension,
organ failure present for emergency surgical worsening pulmonary mechanics, and decreased
patients managed in this manner. These data urine output can all be mistakenly attributed to
suggest that management of general surgical septic shock. Serial physical examination is the
conditions with an open abdomen following key to ensure that ACS is not developing.
index operation is becoming more common, Appropriate blood and fluid resuscitation is dis-
and familiarity with associated techniques and cussed in detail by Dr. Cotton in Chap. 6, and Dr.
anticipated complications is prudent. Ivatury has outlined abdominal compartment
Over the last 10 years, a phased approach to syndrome in Chap. 9.
damage control surgery in both trauma and Secondary intra-abdominal hypertension and
nontraumatic abdominal emergencies has been abdominal compartment syndrome may develop
advocated. As outlined in earlier chapters, the even with an open abdomen following initial
initial phase focuses on goal-directed resusci- damage control surgery. In the initial abbrevi-
tation, hemostasis, and source control in the ated surgery, common abdominal dressings uti-
setting of sepsis. Phase II requires correction lized include sterile plastic sheets (such as sterile
of hypothermia, coagulopathy, and acidosis in x-ray cassette covers) or more recently sophisti-
the ICU. This is followed by definitive repair cated vacuum-assisted closure (VAC) dressings.
of all injuries/pathology and ultimately closure Intra-­abdominal hypertension may develop irre-
of the abdominal wall. While numerous authors spective of the dressing utilized on an open
have demonstrated that utilization of these abdomen. If the abdomen is packed too tightly,
techniques results in successful patient ­salvage, towel packs are too stiff or a VAC dressing too
28  Complications Status Post Damage Control for the General Surgeon 311

Ongoing monitoring of pulmonary pres-

sures as well as bladder pressure is appropriate
in the immediate postoperative period. The
procedure we employ for measurement of
bladder pressure is outlined in detail in
Fig.  28.2. Utilizing aseptic technique, a pres-
sure transducer is set up utilizing the specimen
port from a Foley catheter collection system.
The urine collection tubing is clamped distal to
the specimen port, and via the system depicted
Fig. 28.1  “Silo”-type dressing sewn to the skin of the in the figure, 25 mL of sterile saline is instilled
abdominal wall in setting of significant bowel edema. into the patient’s bladder. An intra-abdominal
This was the second closure in this patient as he devel- pressure measurement is then transduced. After
oped secondary ACS following ongoing resuscitation. As
can be observed, it required two 3 L IV bags to achieve the measurement is taken, one must ensure that
closure. Lap pads are placed in the “lumen” of the IV bags the clamp is removed from the urinary drain-
to prevent sutures from cutting through the plastic age tubing. Consideration should be given to
removal of the dressing and replacement with a
looser dressing for abdominal pressure mea-
tight, the patient may not tolerate even a tempo- surements >20 mmHg. While we recognize
rary closure. A number of clinical parameters that this value is below the classic threshold
may be followed intraoperatively and postopera- for abdominal compartment syndrome, we
tively to monitor for signs of intra-abdominal strongly believe that ongoing intra-abdominal
hypertension. hypertension in this setting results in prolonged
Intraoperatively, during the initial surgery visceral ischemia which perpetuates the SIRS
for control of hemorrhage or source control for response.
sepsis, peak pulmonary pressures can be moni- Alternately, a “quick and dirty” bladder
tored. The patient is optimally sedated and pressure measurement can be executed by
paralyzed at this time. If upon application of laying the patient supine and raising the
­
the temporary abdominal closure dressing the Foley catheter drainage system tubing verti-
peak pulmonary pressures rise to greater than cally over the patient’s pelvis. The height of the
30 mmHg, particularly if pressures were sub- fluid ­column from the pubic symphysis can
stantially lower prior to application of the then be measured in centimeters (1.00 cm
dressing, one must consider the possibility that H2O=0.74 mmHg). A measurement of >27 cm
the dressing is too tight. Some patients, partic- H2O=>20 mmHg and warrants concern for
ularly those in septic shock, have such pro- intra-abdominal hypertension.
found bowel edema as to require a “silo”-type
dressing (see Fig. 28.1). It is our practice to
avoid VAC-type dressings in these patients if 28.3 Rebleeding
the bowel protrudes above the anterior abdo-
men at initial exploration. These patients are Another common complication is bleeding fol-
much better treated with the application of a lowing initial operative intervention. As men-
loose silo-type dressing to avoid unplanned tioned earlier, surgical procedures such as
and often emergent bedside re-exploration as emergent repair of a ruptured abdominal aortic
resuscitation with fluid and blood products is aneurysm exploration for postoperative or post-­
likely to continue in the intensive care unit procedural bleeding or procedures in the already
postoperatively. coagulopathic patient may lend themselves to
312 A. Kunac and D.H. Livingston

Equipment Needed
Indwelling urinary catheter with drainage bag and needleless specimen port
Disinfectant (povidone-iodine solution, chlorhexidine, or alcohol)
Standard intravenous setup with 500 mL of normal saline
20 mL syringe
Transducer and pressure tubing
Clamp for urinary drainage tubing
Setup
Using aseptic technique, set up the manifold system, intravenous container of normal
saline, the 20 mL syringe, and the pressure tubing and transducer as shown in
the figure below.
Open the intravenous fluid and flush the system.
Connect the pressure system setup to the needleless specimen port.
To obtain a measurement, clamp the urinary drainage tubing distal to the specimen
port.
Aspirate 25 mL of the normal saline.
Instill 25 mL of normal saline into the urinary bladder and obtain a pressure reading.
AFTER THE MEASUREMENT, ENSURE THAT THE CLAMP IS REMOVED FROM
THE TUBING.

Normal
saline

20-mL Cable
syringe to monitor
Regular
Infusion
intravenous
port
tubing
Transducer
Air
Pressure
tubing
Flu s h

3-way
stopcock
Urine
specimen
port

Fig. 28.2  How to measure bladder pressure (Adapted from Critical Care Nurse 2012; 32:19–31)

damage control laparotomy. Rebleeding follow- ulation measurements (TEG, ROTEM) may be
ing initial damage control is either from coagu- useful in helping identify coagulation defects but
lopathy associated with acidosis and hypothermia should not be used to determine the need for
and/or circulating undetected anticoagulants or ­re-­exploration. Evidence of early blood loss from
“surgical” bleeding. In the former instance, cor- negative pressure canisters and a need for con-
rection of temperature, acidosis, and coagulation tinuous blood and factor replacement to maintain
factors are what is required, while the latter man- blood pressure are definite indications for emer-
dates early reoperation. In the early postoperative gent reoperation. Worsening acidosis as mea-
period, this can be challenging to determine as sured by base deficit or lactate, the need for the
ongoing surgical bleeding will further compound institution of vasopressor therapy to maintain
coagulopathy and can make correction of hypo- blood pressure, and dropping hemoglobin levels
thermia and acidosis impossible. Advanced coag- despite blood administration are also signs that
28  Complications Status Post Damage Control for the General Surgeon 313

warrant urgent re-exploration. Often, even with- hypovolemic/hemorrhagic shock or source con-
out identifying a surgical source of bleeding, trol and antibiotics in the septic patient.
removal of clotted and non-clotted blood and Unexplained and worsening metabolic acidosis
repacking with fresh lap pads can result in marked may lead to suspicion of nonocclusive mesenteric
improvements in hemostasis. ischemia. Alternately, the intestine may be visi-
ble via a temporary abdominal dressing and
could appear to be poorly perfused. If bowel isch-
28.4 Ischemia emia is suspected for any reason, the underlying
cause must be reversed.
Acute mesenteric ischemia is a condition for
which initial damage control and planned second-­
look operation is appropriate. Ischemia of the 28.5 Anastomotic Leaks
bowel secondary to a low flow state (nonocclu- and Fistulae
sive mesenteric ischemia) is also a potential com-
plication in patients who are so profoundly ill as Perhaps the most feared complications following
to require damage control laparotomy. Each of DCL are anastomotic leaks and fistulae. Whether
these warrants careful consideration. or not to perform anastomoses and how to con-
First, patients who undergo abdominal explo- struct them certainly plays a role in development
ration for acute infarction of the small bowel of anastomotic leaks. When small bowel is
may benefit from a planned open abdomen and resected, with the exception of the distal ileum,
early second look. A planned open abdomen creation of anastomosis to restore intestinal con-
decreases the risk of developing intra-abdominal tinuity is almost always necessary. In accordance
hypertension/abdominal compartment syndrome with usual surgical tenets, anastomoses are con-
as the patient is resuscitated. Necrotic bowel can structed such that they should be tension-free
be resected without performing anastomoses with good blood supply. While there remains no
using bowel of questionable integrity at initial definitive answer as to whether hand sewn or
operation. Progressive bowel ischemia is cer- stapled anastomosis is superior in this setting, in
tainly a potential problem with this particular our experience the marked bowel edema that is
disease process; a clear plastic dressing may be almost uniformly present makes hand-sewn anas-
utilized as a temporary abdominal closure allow- tomosis our construction of choice. More impor-
ing a “window” into the peritoneal cavity should tantly and not often taken into account, following
the patient suffer progression of their bowel elective general surgery is where the anastomosis
ischemia. Finally, the planned second look lies within the peritoneal cavity as it relates to the
allows early reevaluation of segments of the abdominal wound. It is imperative to “bury” the
bowel with questionable viability and potential anastomosis behind the abdominal wall or other
preservation of intestinal segments that may viscera. An anastomosis that ends up in the center
have otherwise been resected and avoidance of of the wound, particularly when the abdomen
possible short gut. cannot be closed, is a “fistula in waiting.” For this
In performing damage control for any indica- reason, we strongly avoid any midline anastomo-
tion, one must also consider that intestinal isch- sis such as gastrojejunostomies or those in the
emia may also occur secondary to the physiologic transverse colon in this patient population.
state of the patient. Diminished splanchnic circu- Whether or not to perform a colonic anasto-
lation secondary to profound shock is common mosis or create an ileostomy or colostomy
and may be exacerbated by vasopressor use. The should be given careful thought. Anjaria et al.
only certain treatment is correction of the under- studied trauma patients with colonic injuries
lying arterial hypoperfusion—this may be by vir- who ­underwent a single laparotomy versus DCL
tue of fluid and blood product infusion in cases of and subsequent re-exploration. Anjaria found
314 A. Kunac and D.H. Livingston

that repair or delayed anastomosis following contents are often too thick to be captured. At
DCL is feasible, with complication rates similar this juncture, it is also almost impossible to close
to single ­ laparotomy when successful fascial the abdominal wall any further, and surgeons
closure is completed on the first post-DCL reop- should realize that a late abdominal wall recon-
eration. However, if fascial closure is not possi- struction will be needed. Fortunately, given
ble on the second operation, patients should be patience on the part of the surgeon, time, nutri-
treated with a stoma because there is an eight- tion, and a bit of ingenuity, almost all fistulae can
fold increase in the incidence of anastomotic be treated successfully.
leak. This suggests that there is a single opportu- As stated above, the goal of entero-­atmospheric
nity to establish colonic continuity after fistula management is control of effluent and
DCL. For those patients who require placement good nutrition. As the opening in the bowel is to
of a colostomy, we strongly advocate placement the outside world, the fistula opening will always
lateral to the rectus sheath. Retaining the fascial have a lower pressure than the distal intestine and
and muscular integrity of the rectus abdominis is thus will most commonly remain open. One
important as these patients have significant exception are those fistulae at the edge of the
wound complications as well as the potential open abdomen-native abdominal wall where
need for later abdominal wall reconstruction wound contraction may increase the pressure
with component separation. gradient in favor of fistula closure. In the early
Fistulae formation following damage control stage of management, we believe and advocate
laparotomy has also been studied. The American achieving as much coverage over the remaining
Association for the Surgery of Trauma estab- viscera as possible. The easiest and most reliable
lished an open abdomen registry and found that way to achieve that goal is through the use of thin
large bowel resection, large-volume fluid resusci- split-thickness skin grafts while making allow-
tation, and an increasing number of abdominal ance to capture as best as possible the effluent
re-explorations were statistically significant pre- from the fistula. We eschew the traditional 3–5-­
dictors of enterocutaneous fistula, entero-­ day period before uncovering the graft as this is
atmospheric fistula, or intra-abdominal sepsis in associated with a 100% graft failure. Rather we
patients with an open abdomen after damage nurse these grafted wounds open which prevents
control laparotomy. For those who require multi- effluent from building up under the new grafts.
ple re-explorations, fistulae are fairly common While some graft loss is inevitable, we often
complications with fistula rates ranging from 5% achieve ≥80% coverage. As the skin graft heals,
to 25%. the wound contracts and allows for eventual man-
Management of the entero-atmospheric fis- agement of fistula effluent with a traditional
tula is one of the most challenging complications colostomy appliance. It is during this time period
following damage control surgery as these often that a fistula at the edge of the wound may actu-
occur within an open granulating wound. It is ally close.
also the reason that there is a significant empha- Fistulae that are away from the edge of the
sis on techniques or approaches to prevent or wound or those that have become “stomas”
minimize this complication. However, once a always require eventual surgical intervention.
patient has developed a fistula, both the patient These secondary operative closures are always
and the surgeon must realize that they are in for challenging but can be made more so by an overly
a long and complicated treatment course as there aggressive timeline. The longer one can wait and
are no quick fixes to this problem. Attempts to temporize, the less hostile the abdomen will be
suture, glue, or otherwise close the fistula are and the less likely for creation of inadvertent
destined to fail and are likely to make the open- enterotomies in the dissection and closure of the
ing larger. Even the use of tubes and catheters to fistula.
attempt to capture the effluent is problematic and In our experience it is 3 months at the earli-
prone to almost certain leakage as the enteric est following closure or healing of all other
28  Complications Status Post Damage Control for the General Surgeon 315

wounds before reoperation is even considered. 28.6 I nability to Close

While not necessarily completely nutritionally the Abdomen
replete, patients must be demonstrating mark-
edly improved nutritional parameters (pre- Following DCL, there is a small group of patients
albumin, transferrin, albumin) prior to where achieving abdominal fascial closure seems
embarking on closure. We advocate nutritional impossible. This may be due to loss of domain in
optimization via enteral feeds whenever possi- cases where the patient had a destructive lesion of
ble. Patients with distal fistulae that have a sig- their abdominal wall or an infection requiring
nificant length of functional small bowel, significant debridement or may be due to retrac-
especially in cases where eating does not sig- tion of the fascia. Others have retroperitoneal
nificantly increase fistula output, should be processes (hemorrhage or pancreatitis) that
allowed to eat (Fig. 28.3). In patients with fis- decrease the intra-abdominal domain.
tulae are tolerating regular diet and can man- A number of techniques have been discussed
age any fluid losses, one can wait even longer for the early closure and late reconstruction of
for repair until the patient is nutritionally opti- the abdominal wall—many of these are dis-
mized. Some patients with proximal fistula, cussed in detail elsewhere (Chaps. 17 and 19).
complete distal obstruction, or other issues that The most common approach is delayed primary
require significant supplemental fluid and/or closure. If delayed closure is possible on the
TPN require intervention as soon as it is feasi- first reoperation, this is preferred. Even sequen-
ble. Quite often these patients do not have the tial closure of the fascia over two or three oper-
resources and ability to be treated at home or at ations is acceptable. Despite success of closing
a skilled nursing facility and therefore remain many damage control trauma laparotomies, the
in the acute care hospital. For these patients in same success has not been necessarily achieved
particular, surgeons have to resist the pressure in the setting of sepsis or other acute care surgi-
and temptation to operate prematurely. cal disasters. Given the risk of fistula formation
if the abdomen remains open, we must accept
that other techniques may be employed to
achieve closure over the abdominal contents. In
patients who have the omentum covering the
abdominal contents, the concern for the devel-
opment of a fistula is much less, and thus more
options for closure are available. These alter-
nate techniques come with an accepted need to
return at a later date to offer definitive repair of
the intentional hernia.
In patients who have a wide defect that has
not been amenable to sequential secondary clo-
sure and insufficient omentum that leads to
exposed bowel, a split-thickness skin graft may
be applied directly over the bowel. There is no
need for granulation tissue to be present, and in
Fig. 28.3  A “simple” mid-small bowel fistula at the edge
of an open abdomen treated with a skin graft. The patient
fact the longer one allows for granulation tissue
has been home eating a regular diet with a stoma bag to occur, the more likely that a fistula will occur.
placed over the fistula. He is now about 9 months and the In patients whose viscera are not “stuck,” we
graft can be easily lifted away from underlying viscera. In routinely sew a Vicryl mesh to the fascial edge
this stage, the fistula was easily dissected free and closed.
The skin graft was sewn to the edge of the wound, and the
so that the mesh overlies the intestine. The mesh
patient underwent formal abdominal wall reconstruction remains in place for about 3 days allowing the
in a clean field, 6 months following fistula closure bowel to become fixed within the peritoneal
316 A. Kunac and D.H. Livingston

Fig. 28.4 Patient who developed complex entero-­ put and the distal limb could not be intubated to deliver
atmospheric fistulae during ongoing care and secondary enteral feeds. Patient managed with TPN until fistula clo-
closure of an open abdomen. Fistula (top of granulating sure when nutritional replete. Wounds (except for fistula)
wound; right photograph, incision) has proximal high out- healed at 3 months following last operation

c­ avity as many of the modern plastic dressings 12 months following skin grafting, the graft is no
prevent adherence of the bowel to the abdominal longer adhered to the bowel and can be easily
wall. Remember that at the time of skin grafting, lifted away from the underlying viscera (see Fig.
minimal movement is ideal, and the bowel that is 28.3). At this point, the patient is a candidate for
adherent is unlikely to eviscerate from beneath a abdominal wall reconstruction.
graft. The Vicryl mesh is easily removed, and Ideally, abdominal wall reconstruction should
thin skin grafts are harvested from available be performed independent of fistula repair or
donor sites, most commonly the anterior thigh, stoma reversal. Fistulae should be repaired prior
and applied directly over the bowel. Commonly to planned hernia repairs. Figure 28.4 depicts a
the proteins on the bowel will allow the skin patient with a complicated midline abdominal
graft to “stick” without any other adhesive nec- wound, multiple fistulae, and an underlying her-
essary. In other cases we have employed other nia. This example reflects a patient in whom
tissue adhesives in small areas to prevent skin nutritional status has been optimized, and timing
graft movement. We routinely use nonadherent is appropriate for definitive repair of his abdomi-
gauze followed by the hydrophilic sponge and nal wall. Given the fistulae, this is accomplished
then a commercial negative pressure dressing to in two stages. The first operation involves tedious
minimize shear forces. The graft is routinely adhesiolysis along with isolation and resection of
unveiled on post-op day 3 or 4. Skin grafting the fistulae (Fig. 28.5). The final operation will be
over bowel results in a giant ventral hernia but repair of the hernia—thus, if mesh is required,
usually abrogates fistula formation. Frankly we this can be accomplished as a “clean” case.
believe that fixing a hernia without a fistula is far Following similar logic, intentional stomas
preferred over dealing with both a late hernia should also be reversed prior to abdominal wall
and an entero-atmospheric fistula! Six to reconstruction.
28  Complications Status Post Damage Control for the General Surgeon 317

intra-abdominal hypertension may develop even

with a temporary abdominal closure from a
dressing applied too tightly. One must also con-
sider that post-op patients may suffer ongoing
hemorrhage and/or bowel ischemia from poor
gut perfusion.
Enterocutaneous fistulae, entero-atmospheric
fistulae, and intra-abdominal sepsis from anasto-
motic leaks are fairly common complications of
the open abdomen. Colonic diversion should be
considered if fascial closure cannot be achieved
at the first re-exploration following DCL. Further,
skin coverage over the abdomen should be sought
Fig. 28.5  Intraoperative appearance of following isola-
tion of two distinct entero-atmospheric fistulae from as soon as possible—the surgeon must be willing
patient in Fig. 28.4. The reason for the inability to intubate to admit when timely primary fascial closure is
the distal limb is now obvious as it was an obstructed not possible and should move to an alternate plan
blind limb between the two fistulae. To achieve successful
such as skin grafting under such circumstances.
outcomes in closing these fistulae, careful and complete
dissection of the viscera is required to ensure all compo- There is no doubt that this group of patients will
nents are identified require more thought and long-term planning and
will tax a surgeon’s ability and ingenuity.
However, adherence to the principles and con-
28.7 S
 etting the Stage for a Good cepts outlined in this chapter and elsewhere will
Outcome result in excellent outcomes in this critically ill
and injured population.
Damage control laparotomy has applications
for the general surgeon and specifically has
been shown to be efficacious for laparotomies Suggested Reading
performed for conditions such as peritonitis,
1. Anjaria DJ, Ullman TM, Lavery R, Livingston
infarcted bowel, severe pancreatitis, ruptured DH. Management of colonic injuries in the setting of
abdominal aortic aneurysm, and postoperative/ damage-control laparotomy: one shot to get it right.
post-procedural hemorrhage. In fact, as the use J Trauma Acute Care Surg. 2014;76:594–8.
of massive transfusion protocols emphasizing 2. Bruns BR, Ahmad SA, O’Meara L, et al. Nontrauma
open abdomens: a prospective observational study.
early blood loss and factors with minimal crys- J Trauma Acute Care Surg. 2016;80:631–6.
talloid resuscitation has decreased the use and 3. Coccolini F, Biffl W, Catena F, et al. The open abdo-
need of damage control/open abdomens follow- men, indications, management and definitive closure.
ing trauma, it is the general surgeon treating World J Emerg Surg. 2015;10:32.
4. Dubose JJ, Lundy JB. Enterocutaneous fistulas in the
intra-­abdominal sepsis and other acute surgical setting of trauma and critical illness. Clin Colon
catastrophes that are performing this technique Rectal Surg. 2010;23:182–9.
most commonly. 5. Finlay IG, Edwards TJ, Lambert AW. Damage control
Successful interventions rely on correcting laparotomy. Br J Surg. 2004;91:83–5.
6. Lee RK. Intra-abdominal hypertension and abdominal
derangements in coagulation, acid, base, and compartment syndrome a comprehensive overview.
body temperature following DCL and before Crit Care Nurse. 2012;32:19–31.
reoperation. When employing DCL, one must 7. Lee JC, Peitzman AB. Damage-control laparotomy.
be aware that there are a number of possible Curr Opin Crit Care. 2006;12:346–50.
8. Weber DG, Bendinelli C, Balogh ZJ. Damage control
complications. While DCL decreases the likeli- surgery for abdominal emergencies. Br J Surg.
hood of abdominal compartment syndrome, 2014;101:109–18.
 DC2 Outcomes of Damage Control
Surgery: General
29
Ben Kautza and Jason Sperry

29.1 Background DCL discussed below will help delineate the data
known to date and highlight the future direction
Trauma is one of the leading causes of death in of therapy and research needed.
individuals 1–44 years of age. Significant abdom-
inal trauma, whether penetrating or blunt, is a
major factor in determining outcomes. During 29.2 Damage Control Laparotomy
initial resuscitative and operative procedures, the
presence of acidosis, hypothermia, and coagu- Damage control is characterized by initial
lopathy has been shown to be associated with resuscitation, brief laparotomy when necessary,
higher mortality (Mikhail 1999; Moore 1996). In continued intensive care unit resuscitation fol-
individuals with major abdominal trauma devel- lowed by planned reoperation. The operative
opment of coagulopathy, metabolic acidosis, approach focuses on arresting hemorrhage (use
hemodynamic instability, infections, and pulmo- of vascular clamps, packing, etc.) for vascular
nary complications have been shown to signifi- or parenchymal injuries, the avoidance of fur-
cantly increase morbidity and mortality (Moore ther peritoneal contamination with stapling of
1998). Since the early 1980s operative techniques hollow viscus injuries (often left in discontinu-
such as damage control laparotomy (DCL) or ity), and in the final stages leaving the abdomen
staged laparotomies have evolved to help reduce open to avoid abdominal compartment syn-
the morbidity and mortality associated with drome (ACS). ACS refers to impaired organ
severe abdominal trauma. DCL has shown bene- function attributed to increased intra-abdomi-
fit in case series and smaller studies; no definitive nal pressure (Richardson 1976). The main aim
randomized control trial exists comparing DCL of damage control laparotomy is to reestablish
to immediate and definitive repair in the treat- physiologic stability and avoid the development
ment of severe abdominal trauma. Outcomes of or worsening of acidosis, coagulopathy, and
hypothermia (Cirrochi 2013). This technique
aims to avoid prolonged surgical intervention
and potentially complex definitive repairs in an
B. Kautza, MD • J. Sperry, MD (*) unstable patient. A potential disadvantage is the
Department of Trauma and Acute Care Surgery,
University of Pittsburgh Medical Center,
need for further operative intervention the
Pittsburgh, PA, United States of America potentially increase in morbidity associated
e-mail: sperryjl@upmc.edu with open abdomens (OAs).

© Springer International Publishing AG 2017 319

H.-C. Pape et al. (eds.), Damage Control Management in the Polytrauma Patient,
DOI 10.1007/978-3-319-52429-0_29
320 B. Kautza and J. Sperry

29.3 Early Experience trauma with hemorrhage with vascular and hol-
and Outcomes in Damage low viscus injuries, DCL contributes to increased
Control Laparotomies survival.
The use of DCL showed increase survival and
The contemporary use of DCL began in the early offered a viable operative strategy for dealing
1980s. A study from Emory University in 1983 with severely injured and exsanguinating trauma
first described the use of aborted laparotomy with patient. Questions on optimal timing of definitive
intra-abdominal pack tamponade in the treatment operative intervention as well as the recognizing
of 17 patients who required laparotomy for morbidity associated with the use of DCL were
abdominal trauma (Stone 1983). The technique investigated. The development of ACS in these
described involved controlling major hemorrhage patients was identified, and strategies to recog-
with vessel ligation or repair and purse-string nize and predict those at risk were questioned.
closure of hollow viscus injury and packing of A series out of Vanderbilt University consist-
the abdomen with abdominal closure under ten- ing of 107 patients undergoing DCL investi-
sion. These patients were then reexplored at gated timing of definitive operation as well as
15–69 h later with 11 patients deemed to have a development of ACS (Morris 1993). In this
“lethal coagulopathy” surviving (Stone 1983). series survival to discharge was 74.1% with
Compared with matched controls undergoing the development of ACS in 15%. Development of
then contemporary standard of care, those under- ACS increased mortality significantly (62.5%).
going aborted laparotomies with packing had a Echoing Rotondo et al. (1993), reversal of hypo-
mortality rate of 35% vs 93%, respectively. thermia, coagulopathy, and acidosis was shown
Interestingly, considering todays knowledge of to be correctable early after initial laparotomy
massive transfusion protocols, there were no sig- and usually within 36 h. The majority of patients
nificant differences in the volume of blood used were able to have definitive surgery and packing
between the groups. However significantly removal within 24–36 h. Interestingly abdomi-
greater volumes of plasma, red cell mass, and nal fascial closure was achieved in 90% of cases
platelets were required in the group who under- (Morris 1993). This series showed the decision
went initial definitive repair (Stone 1983). to proceed with a DCL should be made early
A study out of the University of Pennsylvania and the presence of hypothermia (<35 °C), aci-
in the early 1990s first defined “damage control” dosis (base deficit <−14 mmol/l), and observa-
as the initial control of hemorrhage and contami- tion of medical bleeding were indications to do
nation followed by packing and rapid closure such (Morris 1993).
(Rontondo 1993). This series investigated 46 The potential morbidity of DCL and compli-
patients who required laparotomy for penetrating cations such as ACS led to novel strategies to
injuries who required greater than ten units of red recognize these early as well as novel treatment
blood cells for exsanguination. Overall survival strategies. Initial aggressive resuscitation of
between those undergoing DCL and standard of trauma patients in extremis undergoing DCL can
care was not significantly different. However in a lead to substantial bowel edema making, at
subgroup of patients who had major vascular times, even skin closure challenging. Temporary
injury as well as two or more visceral injuries, abdominal closure after DCL early on was typi-
DCL showed significantly increased survival cally described and achieved with either suture
(77% vs 11%) when compared to initial defini- to achieve tension (Stone 1983) or towel clip
tive operation (Rotondo 1993). This study was skin closure (Feliciano 1988; Morris 1993;
also able to validate that postoperative resuscita- Burch 1992). Burch et al. (1992) were one of the
tion after DCL was able to achieve correction in first to describe the use of a synthetic material to
coagulopathy and acid-base balance as well as achieve coverage of abdominal contents after
restore normothermia prior to planned reopera- DCL. Synthetic material, typically in the form of
tion. Results showing in penetrating abdominal modified intravenous bags, was sewn to the skin
29  DC2 Outcomes of Damage Control Surgery: General 321

to achieve coverage and temporary abdominal truncal injured trauma patient in conjunction
closure in these cases (Burch 1992; Rotondo with DCL. Early experience with the use of intra-
1993; Hirschberg 1994; Raeburn 2001). The use venous bag closures (e.g., Bogota bags) did not
of synthetic material to achieve coverage does decrease the development of ACS or increase
not reduce the risk of ACS development (Raeburn PFC rates (Raeburn 2001). Barker et al. (2000)
2001). The use of these strategies led to patients describe the ideal temporary abdominal wound
with open abdomens whose abdominal fascia closure as one that provides containment of
could not be closed. The use of absorbable mesh abdominal contents, protects abdominal contents
sewn to fascia to achieve abdominal closure after from mechanical injury, prevents contamination
definitive operative intervention was described of the peritoneal cavity, controls peritoneal fluid,
(Morris 1993). Not until later use and develop- and can be rapidly applied and relatively inex-
ment of negative-pressure wound therapy pensive. The development of commercially avail-
(NPWT) systems was ACS risk reduced and able negative-pressure wound therapy (NPWT)
treatment of open abdomens facilitated (Barker systems have become widely developed and meet
2000; Subramonia 2009; Godat 2013; Chiara majority of ideals described by Barker et al.
2016). (2000).
The recognized success of DCL use has led
to the increase in OAs, not only in trauma
29.4 Contemporary Use patients, but other surgical specialties as well.
of Damage Control Care of an OA patient still remains a great chal-
Laparotomies, the Open lenge and sparks debate, despite improved sur-
Abdomen and Outcomes gical interventions and advancements in ICU
care and nutritional support (Al-Khoury 2008;
Damage control operative strategies occur in Becker 2007). Challenges in the OA patients’
10–15% of current trauma laparotomies care have spurred the development of national
(Demetriades 2014). As mentioned previously and international committees and organizations
the use of DCL involves truncated initial opera- dedicated to addressing these issues. Techniques
tion with a temporary abdominal closure strat- for temporary abdominal closure, management
egy; correction of physiologic derangements of OA complications, and challenges as well as
followed by definitive operative intervention and achieving definitive abdominal closure will be
abdominal closure. When DCL strategies are reviewed.
undertaken, typically the abdomen is left open
with some type of temporary abdominal closure
technique in the effort to avoid intra-abdominal 29.4.1 Temporary Abdominal
hypertension and the development of ACS. This Closure in DCL
strategy leads to the relatively common condi-
tion of the open abdomen (OA) in the care of the The use of DCL, as described earlier, allows for
severely injured trauma patient. As noted earlier, rapid termination of the initial operation for cor-
the decision to perform a DCL and the subse- rection in physiologic derangements as well as
quent advancements in trauma resuscitation have eases planned reoperations in cases of hemor-
greatly increased overall survival in this cohort. rhage, abdominal contamination, ischemia, or
However, the care and management of OAs has other indications. Abdominal fascial closure is
needed to focus on strategies to allow for pri- ideal at the conclusion of planned reoperations
mary fascial closure, decrease enterocutaneous after OA and can be achieved in the majority of
fistula (ECF) formation, and decrease overall cases (Barker 2000; Navsaria 2013). Rates of
morbidity. OA complications increase as the period between
Temporary abdominal closure strategies have initial operative intervention and definitive
become instrumental in the treatment of severely closure increases (Redden 2013). Abdominal
­
322 B. Kautza and J. Sperry

fascial closure is best achieved after bowel is typically followed by a macroporous mate-
edema subsides and prior to the formation of rial or sponge followed by an occlusive dress-
dense adhesions and granulation tissue between ing and negative pressure suction. NPWT have
viscera and the abdominal wall (Chiara 2015). become the primary choice for the manage-
However; lateral retraction of the fascial edges ment of OAs (MacLean 2008) and are associ-
in prolonged OA scenarios becomes problematic ated with the highest rates of fascial closure
and at times fascial closure unachievable. and lowest mortality (Quyn 2012; Voele van
Current temporary abdominal closure strategies Hensbroek 2009). Known benefits of NPWT
aim to provide visceral protection, reduce or systems include prevention fascial retraction,
delay development of significant intra-abdomi- decreased adhesion and fistula formation,
nal adhesions, and prevent fascial retraction and titratable suction, peritoneal fluid egress, as
thus abdominal domain loss. well as overall ease of use. In trauma patients
Since the implementation of DCL, various undergoing DCL, peritoneal fluid leak has been
strategies for temporary abdominal closure have shown to contain inflammatory cytokines with
been used including skin approximation, interpo- NPWT use allowing a decrease in cytokine lev-
sition material sutured to fascial edges, or more els (Roberts 2013). Standard suction settings
recently NPWT systems. The use of skin approx- of negative 125 mmHg allow for adequate peri-
imation techniques (i.e., towel clip closure, toneal fluid measurement and collection; in OA
Bogota bags, silo techniques) (Feliciano 1988; patients with coagulopathy, negative 75 mmHg
Morris 1993; Burch 1992; Cipolla 2005; pressure aids in coagulopathy correction (Open
Tremblay 2001) has largely fallen out of favor. 2009). Potential drawbacks of NPWT are their
Skin approximation techniques are prone to sig- availability in certain areas, technical issues
nificant fluid leakage and evisceration and do not with suction maintenance, and the need for fre-
allow for optimal measurement or egress of peri- quent dressing changes (typically every 48 h)
toneal fluid and do not prevent fascial retraction and cost. The increased experience and use of
(Chiara 2015) and can be challenging from a NPWT systems has led a recent international
nursing care standpoint. These techniques still consensus conference to state that NPWT is
place OA patients at risk of ACS development the “best option” in OA management (Chiara
and have been shown to be a risk for fistula for- 2015).
mation (Regner 2012). No investigations to date have rigorously eval-
Interposition patches sewn to fascial edges uated these methods of temporary abdominal clo-
(e.g., Whitman patch; Keramati 2008) do provide sure in a comparative manner. One study out of
a mechanical advantage to reduce fascial retrac- Italy compared the use of a skin approximation
tion. However, they also do not allow for egress technique (Bogota bag) to NPWT system in the
of peritoneal fluid, place viscera at increased treatment of patients with ACS (Batacchi 2009).
risk of mechanical injury, and do not prevent This study looked at prospective use of NPWT
the formation of intra-abdominal adhesions. compared to historical controls (Bogota bag) and
Interposition patch use is known to promote high found that NPWT was significantly more effec-
rate of fistula formation as well as low rates of tive in managing intra-abdominal hypertension
primary fascial closure (Campbell 2010; Open as well as normalizing serum lactate in the first
2009). These patches are best used when fascial 24 h after laparotomy. In addition, NPWT system
closure is known to be unachievable and granula- showed faster abdominal closure rate, decreased
tion tissue is needed for eventual skin grafting duration of mechanical ventilation, as well as
(Chiara 2015). ICU and hospital length of stay; however no sig-
NPWT systems and their iterations typically nificant differences in mortality were shown
involve a porous plastic material that covers (Batacchi 2009). The applicability to the DCL
the bowel to prevent adhesions and allow trauma patient is unknown and highlights the
egress of peritoneal fluid. The following layer need for further investigation.
29  DC2 Outcomes of Damage Control Surgery: General 323

29.4.2 OA Management repeated manipulation of friable and edematous

and Complications bowel (Bradley 2013). As mentioned earlier, tech-
niques for temporary abdominal closure can also
Outcomes in DCL use and subsequent OAs are impact the rate of fistula formation.
defined to an extent by the development of com- Fascial closure is preferred and the most desir-
plications and associated morbidity. Individuals able option in DCL and OAs. Ideally fascia is
undergoing DCL are, by definition, critically ill; closed primarily within the first week after initial
improvement in outcomes has been largely sec- laparotomy. The use of NPWT systems has been
ondary to advances in trauma resuscitation, ICU shown to allow for fascial closure even 3 weeks
care, nutrition, and improved surgical techniques. after initial laparotomy (Miller 2002). Fascial clo-
Steps to prevent complications are needed; their sure at times becomes unattainable and in certain
early recognition is imperative to improve out- patients can be inappropriate to perform. Patients
comes in patients undergoing DCL. with prolonged OA who develop fixed bowel
Individuals post DCL and with OA are in an edema, significant loss of domain, respiratory dis-
extreme catabolic state making nutritional support tress, or tertiary peritonitis should not have their
paramount. Initiation of nutritional support, partic- fascia attempted to close (Open 2009). In instances
ularly enteral nutrition, has been shown to greatly of prolonged OA, a planned ventral hernia is a
improve outcomes in DCL and OAs. Development viable and safe option. The use of a synthetic
of malnutrition in this cohort has been shown to absorbable mesh with subsequent granulation tis-
significantly increase morbidity and mortality sue formation and skin grafting or early skin-only
(Open 2009; Bartlett 1982; Collier 2007; Kudsk closures allows for patient recovery and a planned
1992). It has long been shown that early enteral definitive fascial closure in the future.
nutrition in trauma patients without OAs is associ-
ated with improved outcomes (Moore 1986, 1992). Conclusion
Similarly in DCL patients with OA, early enteral Recognition of severely injured trauma
nutrition improves outcomes. A retrospective patients and development of coagulopathy,
review from the University of Washington found hypothermia, and acidosis should lead the
that early enteral feeding (within 4 days of initial trauma surgeon to employ damage control
laparotomy) slightly improved rates of early strategies in the treatment and resuscitation of
abdominal closure, lower fistula development rates, these patients. Damage control laparotomies
and hospital costs, as well as being independently allow for correction of the lethal triad and
associated with reduction in pneumonia develop- definitive operative interventions under more
ment (Dissanaike 2008). The use of enteral feeding control and most ideal circumstances. The
formulas containing glutamine and 3-fatty acids increased use of these strategies has led to the
may be of benefit through anti-inflammatory complex and challenging scenario of the open
effects (Polk 2012). The use of total parenteral abdomen in trauma patients. Developments in
nutrition is generally reserved for only the temporary abdominal wound closure with
extremely injured (McKibbin 2003) and those with negative pressure systems has allowed for
less than 75 cm of usable bowel (Majorcik 2012). improved care and outcomes early on in dam-
Achieving early abdominal fascial closure has age control scenarios. These improvements
been shown to improve outcomes and avoid the have led to decreased rates of abdominal com-
dreaded complication of fistula formation. Fistula partment syndrome and dreaded fistula forma-
formation can occur in 15% of OA patients when tion. Advances in ICU care and nutritional
early fascial closure is unable to be done within support have played a large impact as well.
8 days of initial laparotomy (Dubose 2010). Further investigations into damage control
Independent risk factors for fistula formation have resuscitation and operative strategies are
been shown to be need for large bowel resection, needed and ongoing and will lead to even bet-
need for large-volume resuscitation, and need for ter care and outcomes in the future.
 Late Outcome After Severe
Fractures
30
Roman Pfeifer and Christian Fang

Over the past decades, numerous improve- 30.1 General Long-Term

ments have been made in the delivery of trauma Outcomes
care and rehabilitation, such as injury preven-
tion, rescue systems, in-hospital diagnostics, It is important to have tools that longitudinally
and various surgical techniques. The mortal- look beyond mortality and predict the patients’
ity rate of multiple trauma patients decreases long-term function. Identifying the early factors
from 37% to 18% during the past two decades that influence long-term outcome following
[1–6]. Polytraumatized patients are likely to major injuries can help physicians identify those
have persisting functional handicaps, long-term that may require special interventions. Several
work disability [7–9], and psychosocial impair- projects [7–9, 13–16] evidence that individual,
ment. The socioeconomic burden on the affected socioeconomic factors and health habits have a
individuals, their families, and society are often strong impact on the outcome on top of injury-­
severe and long lasting [7–12]. related factors, such as injury severity, injury
location, and treatment methods [8, 13, 17]. The
most important poor prognostic factors identified
are as follows [18–20]:

• Patient related
–– Female patients
–– Old age
R. Pfeifer, MD (*) –– High BMI (body mass index)
Department of Orthopaedic Trauma Surgery,
University Hospital Zurich, University of Zurich,
• Injury related
Rämistr. 100, 8091 Zuerich, Switzerland –– Brain injury
Department of Orthopaedic Trauma and Harald-
–– Lower extremity injuries
Tscherne Laboratory, University Hospital Zurich, • Socioeconomic-related factors
University of Zurich, Ramistr. 100, 8091 Zuerich, –– Lower socioeconomic environment
Switzerland –– Lower level of education
e-mail: rpfeifer@ukaachen.de; romanpfeifer@aol.com
C. Fang, FRCS Functional deficits and chronic pain represent the
Department of Orthopaedics and Traumatology, The
University of Hong Kong, Queen Mary Hospital, 102
main factors jeopardizing the quality of life after
Pokfulam Road, Hong Kong, China polytrauma [21]. Up to 60% of severely injured
e-mail: fangcx@gmail.com patients report chronic pain, often caused by injuries

© Springer International Publishing AG 2017 325

H.-C. Pape et al. (eds.), Damage Control Management in the Polytrauma Patient,
DOI 10.1007/978-3-319-52429-0_30
326 R. Pfeifer and C. Fang

to the lower extremity. Thirty-five percent of patients extremity injuries accounted for the most fre-
require long-term analgesic treatment [19, 21]. quent causes of long-term disability [16]. At fol-
Twenty-four to 39% of patients after having low-­up, 33% of patients required a medical aid
multiple injuries were diagnosed with posttrau- for their disability, and 20.1% reported disability
matic distress syndrome, 32–70% with anxiety dis- due to their injury. The results from this study are
order, and 35–68% with depression. Additionally, summarized in the following sections.
cognitive defects, such as memory impairment, dif-
ficulty with concentration, and emotional problems
have been reported [7, 13, 22–24]. These studies
stress the strong need for routine early posttrau- 30.2 Upper Extremity Injuries
matic psychological support.
Self-efficacy was shown to be one of the stron- A limited number of information is available
gest predictors of the Sickness Impact Profile and regarding the outcome of upper extremity inju-
return to work [7–9, 13]. It is hypothesized that ries. Some isolated fractures [33, 34] are associ-
patients with low self-efficacy are more likely to be ated with low-energy mechanisms [33] and are
disengaged from the physical rehabilitation and thereby different from those of severely injured
recovery process. To address this issue, self-­efficacy patients who have sustained high-energy trauma.
and self-management training should be prescribed At long term, patients with injuries to the upper
to polytrauma patients, especially as benefits have limb generally have better outcomes than patients
already been demonstrated in the treatment of with lower extremity injuries [35, 36].
patients with other chronic diseases such arthritis, Nevertheless, concomitant vascular and neuro-
diabetes, and chronic pain syndromes [25, 26]. logical injuries (involvement of brachial plexus
Several groups have shown gender-related dif- and peripheral nerves) were found to be a major
ferences in the well-being after severe injuries determinant for poor recovery [37]. Additional
[16, 27]. Premenopausal women seem to have adverse sequelae following upper extremity
better short-term outcome than men in the acute trauma include nonunion, heterotopic ossifica-
phase [16, 27]. However, long-term results dem- tion, and impaired range of motion [34, 38, 39].
onstrate the opposite, as females are more likely Mkandawire and coauthors analyzed the
to have a higher incidence of psychological dis- 5-year musculoskeletal recovery in survivors of
orders and poorer long-term results [28–31]. severe injuries (ISS >15) [11]. They performed a
A lower socioeconomic status has been reexamination of 158 severely injured patients
reported to be associated with negative long-term (>15 years old) treated between 1989 and 1990.
outcomes [32]. In patients that are injured during According to this multicenter investigation (16
their working age (20–50 years), financial impact hospitals), 48% of patients with shoulder girdle
and unemployment rate were frequently substan- injury and 66% of those with arm and forearm
tial [32]. In contrast, younger patients (≤18 years) fractures had persistent disabilities. Displaced
appear to be more capable of adapting to disabili- fractures and articular fractures were identified as
ties and sustained life changes and are more poor prognostic factors. Remarkably, at 5 years
likely to return to work. Despite this fact, social following trauma, 45% of patients with shoulder
deprivation (loss of friends or social environ- girdle and 62% of those with upper extremity
ment) was more often reported by younger fractures still complained of chronic pain. In par-
patients. This includes failure of exams in stu- ticular, 75% of those with combined ipsilateral
dents and the requirement to switch school [32]. fractures of the shoulder girdle and arm had long-­
Many of the findings reported below were term disabilities. Moreover, authors have hypoth-
generated in a study with a minimum follow-up esized that associated head, facial, and thoracic
of 10 years (mean 17.5 years) [14–16]: It sum- injuries can potentially interfere with rehabilita-
marizes data from 637 patients that were reexam- tion, resulting in continuing disability and pain.
ined at least 10 years after their initial injuries. The 10-year follow-up study addressed above
One of its main findings was that head and also looked at long-term outcomes following
30  Late Outcome After Severe Fractures 327

Table 30.1  Functional status of the upper extremities a­ bdomen, thorax, and head [45, 46]. Because of
following polytrauma with fractures at different
these accompanying injuries, it is harder to ana-
localizations
lyze the long-term outcomes with regard to the
Articular Shaft Combined
pelvis alone [47–49]. It has been shown that
fractures fractures fractures
N = 60 N = 37 N = 52 both the severity of fracture (stable vs. unstable)
ROM >50% 88.3% 94.6%a 73.1%b and the presence of associated injuries contrib-
Contractures 8.3%a 10.8% 25%c ute to poor long-term outcome [50]. Patients
Stiffness 1.6% 2.7% 5.8% with unstable pelvic ring injuries and additional
Neurological 11.7% 10.8% 13.5% associated injuries typically do poorly [49, 51].
impairment Incomplete recovery and functional impair-
Full muscle 90% 97.3% 88.5% ments are commonly observed following unsta-
force shoulder
ble pelvic ring fractures, while stable pelvic
Full muscle 86.7% 100%a 80.8%b
force elbow injuries rarely lead to major long-term problems
HASPOC— 70.2 ± 48.9b 47 ± 34.3a, c 69.4 ± 44.4b [45, 51, 52]. Open pelvic fractures, in particular,
total carry poor prognosis [53]. Patients with com-
SF-12 Phy 43 ± 11.9b 47.9 ± 9.8a, c 43.6 ± 9.9b bined anterior and posterior pelvic ring injuries
HASPOC Hannover Score for Polytrauma Outcome, SF- typically have inferior outcomes (SF 12) versus
12 Phy Short-Form 12 items health survey, Physical those with isolated anterior or posterior ring
Component Summary injuries. In the long term, 39% of patients who
a
Significantly worse outcome vs. combined fractures suffered pelvic ring injuries had a limp and 11%
(p < 0.05)
b
Significantly worse outcome vs. shaft fractures (p < 0.05) required crutches [54].
c
Significantly worse outcome vs. articular fractures Chronic pain syndrome, neurological impair-
(p < 0.05) ment, and nonunion are negative factors that
influence the long-term outcomes after pelvic
fractures (Table 30.2) [52]. Pohlemann and
upper extremity fractures and separated three coworkers reviewed the incidence of pelvic frac-
groups: (1) isolated upper extremity articular ture patients with chronic pain [50, 52, 55]. At
fractures, (2) isolated shaft fractures, and (3) 2 years, 45% of patients with type A-Type frac-
combined shaft and articular fractures tures, 59% with B-Type, and 73% with C-Type
(Table 30.1). Out of the three groups, those with fractures fracture had pain [50, 52, 55].
combined shaft and articular fractures had sig- Nonanatomic reduction or insufficient fixation
nificantly worse outcomes in terms of limitations leads to chronic back pain, instability, malunion,
in range of motion (ROM), presence of contrac- and nonunion [46, 56, 57].
tures (25%), and muscle weakness (10–20%). There is a close correlation between neuro-
Patients with isolated shaft fractures have the logical injury and long-term functional outcome
best prognosis in a general rehab score and in [48]. At 2 years, 21% of patients with B-Type
SF-12 scores when compared with those that had and 60% with C-Type fractures continued to
articular and combined injuries. This may be a have at least some degree of neurological impair-
result of a high-­energy injury background, com- ment [58]. In particular, vertically unstable inju-
plicated rehabilitation, and degenerative joint ries and transforaminal sacral fractures were
diseases that commonly follow articular fractures shown to be associated with more severe neuro-
[40–44]. logical deficits [59, 60]. The sequelae of neuro-
logical compromise include peripheral motor
and sensory disturbances, incontinence, and
30.3 Pelvic Fractures sexual dysfunction [47, 50–53, 55, 57, 58], and
these sequelae result in work disability [46].
Pelvic fractures are often caused by high-energy Approximately 50–75% of pelvic fracture
trauma and are associated with multiple con- patients are expected to be able to return to their
comitant injuries of the lower limb, spine, previous occupation [47, 51, 53].
328 R. Pfeifer and C. Fang

Table 30.2  Clinical examination of pelvic ring fractures following polytrauma

Functional Neurologic
Study Fracture type Follow-up Patienta Pain disability RTW impairments
Pohlemann 1994 Unstable 2.2 years 58 11– No data No data 21–60%
fractures 66%
Miranda 1996 Pelvic ring 5 years 80 16– 8–21% 75–81% No data
fracture 35%
Tornetta 1996 Unstable 3.7 years 48 37% 37% 67% 35%
fracture
Brenneman 1997 Open 4 years 27 No data No data 64% 18%
fracture
Kabak 2003 Unstable 3.8 years 36 31% No data 72% 16–31%b
fracture
Suzuki 2007 Unstable 3.9 years 57 No data No data 84% 28%
fracture
RTW Return to work
a
Skeletally immature patients
b
Sexual and urinary dysfunction

30.4 Lower Extremity Fractures tidimensional self-reported measurement tool

[7–9, 13]. The results demonstrated comparable
Lower extremity injuries are especially important functional outcomes in both groups. However,
in causing long-term loss of function [35, 61–63]. regardless of the treatment option, both the limb
Polytrauma patients with lower limb involvement salvage and amputation groups had severe long-­
have a poorer prognosis than those without [61, term disabilities. One-half of all patients had
62]. Even after 2–5 years, patients rarely have physical subscores on the Sickness Impact Profile
full recovery and overall satisfaction [11, 12]. ≥10, indicative of significant disability; only
Especially those with complex fractures, dysvas- 34% of patients achieved scores comparable to
cular limbs, major soft tissue injuries, and severe the uninjured. Only 58% of those working before
foot and ankle injuries often experience pro- the injury remained employed after 7 years. Of
longed recovery with a high incidence of compli- those who returned to work, 20–25% were unable
cations and frequently require reoperations to perform tasks at their pre-injury level.
including amputations [64]. In addition, those Moreover, no significant improvements were
with concomitant acetabular and lower extremity observed from the second-year to the seventh-­
fractures seem to also do particularly worse. As year follow-up.
with upper limb injuries, patients with articular The 10-year study addressed before [14–16]
involvement have significantly worse outcomes demonstrated the following long-term results
than those with isolated shaft fractures [65]. (Table 30.3): 30–45% of patients experienced
The Lower Extremity Assessment Project posttraumatic pain, and approximately 10–30%
(LEAP) [7–9, 13] is a prospective study that reported limited range of motion. High rates of
included eight level I trauma centers. Long-term gait abnormality were observed in patients who
functional outcomes of 601 patients were sustained acetabular fractures, while lower rates
assessed; patients with major leg-threatening of gait abnormalities were observed following
injuries were grouped under two main treatment femur shaft fractures. Outcome scores were sig-
categories: (1) limb salvage or (2) amputation. nificantly better following an isolated femur
The study included patients with open fractures, shaft fracture as compared to those with acetab-
dysvascular limbs, major soft tissue injury, and ulum and knee joint involvement. The observed
severe foot and ankle injuries. Outcomes were rates of arthroplasty were 7.5% for the hip joint
graded using the Sickness Impact Profile, a mul- and 15.1% for the knee, and 12.3% had ankle
30  Late Outcome After Severe Fractures 329

Table 30.3  Functional status of the lower extremities following polytrauma with fractures at different localizations
Acetabulum Prox. femur Femoral shaft Tibial shaft
N = 20 N = 20 N = 107 Kneee N = 48 N = 34
Persistent pain 50.0% 45.0% 32.7% 43.8% 26.5%
Abnormal gait 35.0%a, b 20.0%a 3.7% 8.3% 14.7%a
Work disability 27.8%a, c, d 10.0% 7.6% 19.8% 8.8%
Successful 70.0% 60.0%a 80.4% 56.3%a 67.7%
rehabilitation
HASPOC—total 78.78a 70.07a 49.71 79.28a 65.73
SF-12 PCU 40.91a 40.95 46.05 39.81a 44.06
HASPOC Hannover Score for Polytrauma Outcome, SF- 12 PCU Short-Form 12 items health survey, Physical
Component Summary
a
Significantly worse outcome vs. femoral shaft fractures (p < 0.05)
b
Significantly worse outcome vs. injuries at the knee joint (p < 0.05)
c
Significantly worse outcome vs. fractures of the proximal femur (p < 0.05)
d
Significantly worse outcome vs. tibial shaft fractures (p < 0.05)
e
Knee: including fractures of the distal femur and proximal tibia

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 Index

A Abusive head trauma (AHT), 241

Abbreviated Injury Scale (AIS), 28 ACA. See Affordable Care Act (ACA)
Abdomen, abbreviated surgery Acidosis, 43
abdominal major vascular injuries, 153–154 ACS. See Abdominal compartment syndrome (ACS)
aorta, 153–154 Activated clotting time (ACT), 47
bile duct, 152–153 Activated partial thromboplastin time (aPTT), 43
cava, 153–154 Activation of protein C (aPC), 44–45, 62
colon, 152 Acute coagulopathy of trauma (ACoT), 44, 62
duodenum, 152–153 Acute coagulopathy of trauma-shock (ACOTS), 44
genitourinary (GU) system, 154–155 Acute respiratory distress syndrome (ARDS), 79
laparotomy, 151 Acute traumatic coagulopathy (ATC), 41, 43
liver, 151–152 identification, 46–47
pancreas, 152–153 mechanisms of, 44
small intestine, 152 Adults
spleen, 152 age-related physiologic alterations in, 250
stomach, 152 injury, mechanisms and patterns of, 250–251
Abdomen, inability to close, 315–317 management, principles of
Abdomen, penetrating injuries and damage primary operative phase, 252–258
control surgery to, 291–293 resuscitation at admission, 252
Abdominal/chest wall closure secondary operative phases, 258
laparotomy, 207–208 triage, 251–252
definitive reconstruction, 209–210 Advanced trauma life support (ATLS), 59–60, 250–251
operative approach, 210–212 Affordable Care Act (ACA), 15, 16
planned ventral hernia, 208–209 AHT. See Abusive head trauma (AHT)
temporary coverage of open abdomen, 208 AIS. See Abbreviated Injury Scale (AIS)
thoracotomy Anastomotic leaks and fistulae, 313–315
chest wall reconstruction, 213 ATLS. See Advanced trauma life support (ATLS)
resuscitative thoracotomy (RT), 212
rigid fixation, 213
soft tissue injury, 213 B
Abdominal compartment Biochemical markers, 188–190
syndrome (ACS), 310–311, 319 Bloody vicious cycle, 41, 42
historical background, 97–98
and intra-abdominal hypertension
(IAH), 98, 101–104 C
management, 100–101 Cardiac aneurysms, 82
pathophysiology Cardiac injuries, 82
abdominal visceral abnormalities, 99–100 Cardiac ruptures, 82
abdominal wall abnormalities, 100 CARS. See Compensatory anti-inflammatory
cardiovascular effects, 99 response (CARS)
polycompartment syndrome, 100 CCATTs. See Critical Care Air Transport Teams
pulmonary dysfunction, 99 (CCATTs)
Abdominal major vascular injuries, 153–154 Chest, penetrating injuries and damage control
Abdominal wall closure, 183–184 surgery, 288–291

© Springer International Publishing AG 2017 333

H.-C. Pape et al. (eds.), Damage Control Management in the Polytrauma Patient,
DOI 10.1007/978-3-319-52429-0
334 Index

Chest trauma rapid transport to definitive care, 20–21

chest wall injuries, 80 resuscitation, 21
classification trauma, general surgical approach in, 19–20
Abbreviated Injury Scale (AIS), 84 Damage control laparotomies (DCL), 319
CT-Dependent Wagner Score, 85–86 experience and outcomes in, 320–321
Pulmonary Contusion Score (PCS), 84–85 OA management and complications, 323
Thoracic Trauma Severity Score (TTS), 86 temporary abdominal closure in, 321–322
deadly dozen, 83 Damage control orthopedics (DCO), 88–89
diagnostics Damage control phase III (DC III)
bronchoscopy, 84 abdominal wall closure, 183–184
computed tomography (CT), 83–84 gastrointestinal injury, 181–183
plain chest X-ray, 83 repair of injuries, 179–180
thoracic ultrasonography, 84 repair of vascular injury, 180
intrathoracic organs solid organ abdominal injuries, 180–181
diaphragm injuries, 81 Damage control resuscitation (DCR), 21, 23
lung injuries, 81–82 acidosis, 58–59
to mediastinum, 82–83 after bleeding stopped, 65–67
pleural injuries, 81 before bleeding stopped
treatment advanced trauma life support (ATLS), 59–60
airway management, 87 fibrinolysis prevention, 62
mechanical ventilation, 87 haemostatic resuscitation, 62–63
multiple-trauma patients with thoracic trauma, 88–90 red blood cell transfusion, 61–62
positioning therapy, 87–88 restrictive fluid administration, 60–61
surgical chest wall stabilization, 90 targeted blood pressure with permissive
Chest wall reconstruction, 213 hypotension, 60–61
Child abuse, pediatric trauma, 241 vasopressor agents, 61
Chronic obstructive pulmonary disease (COPD), 250 viscoelastic techniques, 63–65
Chylothorax, 81 coagulopathy, 58–59
Clavicular fractures, 80 hypothermia, 58–59
Coagulopathy lethal triad, 58–59
activation of protein C (aPC), 44–45 pediatric trauma
fibrinolysis, 45 acute traumatic coagulopathy, 235
traumatic brain injury-associated coagulopathy, directed resuscitation, 236–237
45–46 massive transfusion in, 235–236
Compensatory anti-inflammatory response (CARS), 35 permissive hypotension, 237–238
Continuous axial rotational therapy, 88 thromboelastography, 236–237
Conventional coagulation tests (CCT), 47 physiological bleeding control, 57–58
Critical Care Air Transport Teams (CCATTs), 280 Damage control surgery (DCS)
Cytokines, 36 ICU care
acidosis, 175
coagulopathy, correction of, 173–174
D hypothermia, 174–175
Damage-associated molecular patterns (DAMPs), 34 mechanical ventilation, 169–170
Damage control resuscitation, 170–172
abdominal closure, 22 pediatric trauma, 238–239
in elderly child abuse, 241
age-related physiologic alterations in, 250 hollow viscus injury, 240–241
injury, mechanisms and patterns of, 250–251 kidney and pancreas injury, 240
primary operative phase, 252–258 liver injury, 239–240
resuscitation at admission, 252 splenic injury, 239
secondary operative phases, 258 DCR. See Damage control resuscitation (DCR)
triage, 251–252 Decision making, clinical parameters for, 190–191
hemorrhage and contamination, 21 Definitive reconstruction, 209–210
indications for Dendritic cells (DCs), 36
abdominal compartment syndrome, 24 Diaphragm injuries, 81
associated injuries, 23–24 Disseminated intravascular coagulation (DIC), 44
early decision making, 22–23
planned reoperation, 24
triad of death, 23 E
injury, historical management of, 19 Early total care (ETC), 88–89
operative repairs, 21–22 Early trauma-induced coagulopathy (ETIC), 44
principles, expansion of, 24 EDH. See Epidural hematomas (EDH)
Index 335

Emergency department (ED) thoracotomy, 146–148 emergency thoracotomy, 146–148

Emergency Medical Services (EMS) system, 3, 6, 7 esophagus, 150
Endovascular damage control great vessels, 148–149
angiography, 118–121 heart, 148
embolization, 118–121 lungs, 149–150
resuscitative endovascular balloon occlusion pulmonary arteries, 148–149
of the aorta (REBOA), 122–125 pulmonary veins, 148–149
ED and pre-hospital environments, 125 temporary thoracic closure, 150
hybrid trauma OR, 125–126 trachea and bronchi, 149
intra-abdominal foam, 127 General surgery approach
novel hemostatic tools, 126–127 contamination, 114–115
training and credentialing, 125 hemorrhage control, 113–114
stent grafting, 121–122 indications, 111
Enterocutaneous fistula (ECF), 321 mechanism/injury pattern, 112
Epidural hematomas (EDH), 73 open abdomen, management of, 115
ESICM. See European Society of Intensive Care patient factors, 112
Medicine (ESICM) physiologic derangements, decision making, 112–113
Esophageal injuries, 82 Genitourinary (GU) system, 154–155
European Society of Intensive Care Medicine Glasgow Coma Score (GCS), 135
(ESICM), 104 Good outcome, Stage for, 317
Extremities, penetrating injuries and damage Great intrathoracic vessels, injuries of, 82–83
control surgery to, 293–294

H
F Head, abbreviated surgery, 143
Fibrinogen, 63 nasopharyngeal and oropharyngeal bleeding, 144
Fibrinolysis, 45 scalp and soft tissue injuries, 144
Flail chest injuries, 80 traumatic brain injury (TBI), 143–144
Fluid resuscitation, 136 Head injury
Focused abdominal sonogram for trauma (FAST), 134 with cranial facial injury, 75
decision-making flow sheet, 72
initial assessment, 73–74
G with major chest/abdominal injury, 74–75
Gastrointestinal injury, repair of, 181–183 with orthopedic injury, 76
Gastroschisis, 242 penetrating injuries and damage control
General surgeon, damage control for, 309–310 surgery, 285–288
General surgery (abbreviated surgery) with spine injury, 75–76
abdomen Hemothorax, 81
abdominal major vascular injuries, 153–154 Highway Safety Act of 1966, 6
aorta, 153–154 Hollow viscus injury, pediatric trauma, 240–241
bile duct, 152–153 Hypothermia, 42–43, 58–59, 235
cava, 153–154
colon, 152
duodenum, 152–153 I
genitourinary (GU) system, 154–155 The Injury Prevention and Control Center, 3
laparotomy, 151 Injury severity score (ISS), 42
liver, 151–152 Innate immune cells, 36
pancreas, 152–153 Intensive care unit (ICU) care, DCS
small intestine, 152 acidosis, 175
spleen, 152 coagulopathy, correction of, 173–174
stomach, 152 recombinant factor VIIa (rFVIIa), 174
head, 143 tranexamic acid (TXA), 174
nasopharyngeal and oropharyngeal bleeding, 144 hypothermia, 174–175
scalp and soft tissue injuries, 144 mechanical ventilation, 169–170
traumatic brain injury (TBI), 143–144 resuscitation
neck blood transfusions, 172
esophagus, 145–146 crystalloids, type of, 172
trachea, 145 crystalloid vs. colloid debate, 171–172
vascular, 144–145 end points, 170–171
thorax Intra-abdominal hypertension, 310–311
aorta, 148–149 Intra-abdominal pressure (IAP), 98, 241
cava, 148–149 Ipsilateral femoral and tibial shaft fractures, 164
336 Index

Ischemia, 313 MODS. See Multiple organ dysfunction syndrome (MODS)

Ischemia-reperfusion injury, 33 Monocytes/macrophages, 36
Mortality, polytrauma, 30–31
MTP. See Massive transfusion protocols (MTP)
K Multiple organ dysfunction syndrome (MODS), 79
Kidney injury, pediatric trauma, 240 Multiple organ failure (MOF), 38
Myocardial contusions, 82

L
Laparotomy, 151, 207–208 N
definitive reconstruction, 209–210 Neck, abbreviated surgery
operative approach, 210–212 esophagus, 145–146
planned ventral hernia, 208–209 trachea, 145
temporary coverage of open abdomen, 208 vascular, 144–145
Late outcome, after severe fractures Neck, penetrating injuries and damage control
general long-term outcomes, 325–326 surgery, 285–288
lower extremity fractures, 328–329 Needle thoracentesis, 135–136
pelvic fractures, 327–328 Neutrophils, 36
upper extremity injuries, 326–327
Lethal triad
acidosis, 43 O
ATC identification, 46–47 Open abdomen (OA), damage control
coagulopathy laparotomies (DCL), 323
activation of protein C (aPC), 44–45 Operative approach, 210–212
fibrinolysis, 45 Orthopaedic surgery
traumatic brain injury-associated chest injuries, absence of, 163–164
coagulopathy, 45–46 chest injury, presence of, 164
damage control resuscitation (DCR), 58–59 decision-making, 107–110
history, 41–42 early orthopaedic fracture fixation, 159–160
hypothermia, 42–43 inflammatory markers, 107
treatment, 48–49 ipsilateral femoral and tibial shaft fractures, 164
Liver injury, pediatric trauma, 239–240 long bone fractures, 163–164
Lung injuries, 81–82 pelvic trauma and packing, 164–165
polytrauma grading score (PTGS), 160, 161
safe definitive surgery concept, 160–163
M Orthopedic injuries, fixation principles for, 192–193
Major injury
coagulation cascade, 37
complement activation, 37 P
gut barrier failure, 36–37 Pancreas injury, pediatric trauma, 240
immune response to, 33–35 Pediatric trauma
innate immune cells abdominal compartment syndrome (ACS), 241–242
dendritic cells (DCs), 36 abdominal wall defects, 242
monocytes/macrophages, 36 anatomy and physiology
neutrophils, 36 anatomic predisposition to injuries, 234
multiple organ failure (MOF), 38 hemodynamics, 234
systemic inflammatory response syndrome hypothermia, 235
(SIRS), 33, 36–37 congenital diaphragmatic hernia (CDH), 243–244
Massive transfusion, pediatric trauma damage control resuscitation
component blood therapy ratios, 236 acute traumatic coagulopathy, 235
in pediatric centers, 236 directed resuscitation, 236–237
in pediatric patients, 235–236 massive transfusion in, 235–236
Massive transfusion protocols (MTP), 48 permissive hypotension, 237–238
Mediastinal hematoma, 82 thromboelastography, 236–237
Mediastinum, 82–83 damage control surgery, 238–239
Medical Emergency Response Team (MERT), 276 child abuse, 241
Military casualties hollow viscus injury, 240–241
hospital, 277–280 kidney and pancreas injury, 240
OCONUS/CONUS, 280 liver injury, 239–240
prehospital, 275–277 splenic injury, 239
Index 337

necrotizing enterocolitis (NEC), 243 vascularized composite allotransplantation (VCA),

trauma in children, epidemiology of, 233–234 203–204
Pelvic angiography, 225–226 Platelet depletion or dysfunction, 63
Pelvic hemorrhage, 220 Pleural injuries, 81
Pelvic packing, 226–227 Pneumomediastinum, 82
Pelvic ring injuries Pneumothorax, 81
hemipelvectomy, 230 Polymorphonuclear leukocytes (PMN), 34
with hemodynamic instability, 227–229 Polytrauma
ongoing treatment, 229–230 age and body area, 30–31
and hemorrhage causes, 29–30
acute fracture fixation, 224–225 and changes over time, 30
arterial inflow arrest, 223 definition, 28
embolization, 225–226 demography, 29–30
external fixation, 223–224 epidemiology of, 28–29
invasive measures, 223 incidence within trauma registry, 29–30
noninvasive measures, 222–223 injury, global burden of, 27–28
pelvic angiography, 225–226 mortality, 30–31
pelvic packing, 226–227 outcome, 30
on hospital course Polytrauma Grading Score (PTGS), 108, 160, 161
initial assessment, 221 Pragmatic, randomized optimal platelet and
pelvic hemorrhage, 220 plasma ratios (PROPPR) study, 48
radiographic assessment, 221–222 Prehospital damage control
Pelvic X-ray (PXR), 221 damage control management
Penetrating injuries and damage airway management, 135
control surgery avoiding hypothermia, 137
to abdomen, 291–293 fluid resuscitation, 136
chest, 288–291 hemorrhage control procedures, 134–135
to extremities, 293–294 needle thoracentesis, 135–136
head and neck, 285–288 tranexamic acid (TXA), 136–137
management, 283–285 triage and rapid transport, 137–139
Peripheral blood mononuclear cells (PBMC), 34 prehospital ABC score, 134
Physiological and Operative Severity Score for prehospital lactate, 134
enumeration of Mortality and morbidity shock index (SI), 133
(POSSUM) scoring system, 309 Prompt and rapid endovascular strategies
Pin-tract infection in trauma occasions (PRESTO), 119
damage control, indications for, 298–299 Prospective, observational, multicenter,
pin-site infection, diagnosis and treatment of, major trauma transfusion (PROMMTT)
301–302 study, 48
spanning external fixation Prothrombin time (PT), 43
pin insertion technique, 300 PTGS. See Polytrauma Grading Score (PTGS)
pin-site care, 301 Pulmonary contusions, 81
placing pins, 299–300 Pulmonary lacerations, 81
stability, 300 PXR. See Pelvic X-ray (PXR)
technique for exchange, 305
temporary to definitive fixation, 302–305
Planned ventral hernia, 208–209 R
Plasminogen activator inhibitors (PAI1 and 2), 62 Rebleeding, 311–312
Plastic surgery Recombinant factor VIIa (rFVIIa), 174
flap reconstruction Resuscitative endovascular balloon occlusion
medial femoral condyle, 202 of the aorta (REBOA), 122–125, 149
unique lower extremity considerations, 199–200 ED and pre-hospital environments, 125
unique upper extremity considerations, 201 hybrid trauma OR, 125–126
vascularized bone grafting, 201–202 intra-abdominal foam, 127
ladder of reconstruction, 196–198 novel hemostatic tools, 126–127
orthopedic trauma surgery, 196 training and credentialing, 125
orthoplastics, 195 vascular injury
microsurgery in, 195–196 complications, 265
postoperative care, 203 courses, 265
reconstructive algorithm principles, 196 indications, 264
soft tissue coverage, 198–199 technique, 265
338 Index

Resuscitative thoracotomy (RT), 212 temporary thoracic closure, 150

Revised injury severity classification (RISC), 48 trachea and bronchi, 149
Rib fractures, 80 Thrombin time (TT), 43
Rigid fixation, 213 Thromboelastography (TEG), 42, 46
Road traffic collisions (RTC), 27, 29, 30 Tissue plasminogen activator (tPA), 62
Rotational thromboelastometry (ROTEM), 46 Toll-like receptors (TLRs), 34
Tracheobronchial injuries, 82
Tranexamic acid (TXA), 48–49, 136–137, 174
S Transfusion Requirements in Critical Care (TRICC), 62
Safe definitive surgery concept, 160–163 Trauma Audit and Research Network (TARN), 28, 29
Scapula, fractures of, 80 Trauma-induced coagulopathy (TIC), 44
SCCM. See Society of Critical Care Medicine (SCCM) Trauma injury severity score (TRISS), 48
SDH. See Subdural hematomas (SDH) Trauma systems
Secondary orthopedic stabilization, 191 Affordable Care Act (ACA), 15, 16
Secondary surgery, effects of, 190–191 death, leading causes of, 3
Serial rib fractures, 80 implementation, 13–15
Severe fractures, late outcome after new era, 9–10
general long-term outcomes, 325–326 optimal design elements, 11–13
lower extremity fractures, 328–329 process of, 4–9
pelvic fractures, 327–328 public health model of, 12
upper extremity injuries, 326–327 Traumatic aortic injuries, 82
Society of Critical Care Medicine (SCCM), 104 Traumatic brain injury (TBI), 30, 31
Soft tissue injury, 213 abbreviated surgery, 143–144
Solid organ abdominal injuries, 180–181 and coagulopathy, 45–46
Splenic injury, pediatric trauma, 239 Traumatic hemorrhage, 41
Sternal fractures, 80 TXA. See Tranexamic acid (TXA)
Sternoclavicular dislocations, 80
Subdural hematomas (SDH), 73
Surgical stress V
endocrine response, 188 Vacuum-assisted closure (VAC), 310
inflammation, 188 Vascular injury
sympathetic nervous system, 188 flow restoration
Systemic inflammatory response syndrome (SIRS), 33, complex repairs and grafts, 269
36–37, 79 definitive occlusion, 269–270
lateral repair, 269
shunts, 266–268
T stents, 269
Temporary coverage, open abdomen, 208 hybrid rooms
TEVAR. See Thoracic endovascular aortic repair general operative techniques, 265–266
(TEVAR) temporary occlusion, 266
Thoracic endovascular aortic repair (TEVAR), 121 REBOA
Thoracotomy complications, 265
chest wall reconstruction, 213 courses, 265
resuscitative thoracotomy (RT), 212 indications, 264
rigid fixation, 213 technique, 265
soft tissue injury, 213 repair of, 180
Thorax, abbreviated surgery Viscoelastic techniques (VETs)
aorta, 148–149 clot viscoelastic property studies, 63–64
cava, 148–149 and coagulation factor concentrates, 64–65
emergency thoracotomy, 146–148 coagulopathy diagnosis by, 64
esophagus, 150
great vessels, 148–149
heart, 148 W
lungs, 149–150 World Society of Abdominal Compartment
pulmonary arteries, 148–149 Syndrome (WSACS), 98, 101, 104
pulmonary veins, 148–149