Damage control surgery (DCS)
The goal of damage control surgery (DCS) is to control surgical bleeding and limit gastrointestinal ( GI) spillage. The operative techniques used are temporary measures, with definitive repair of injuries delayed until the patient is physiologically replete. Small GI injuries (stomach, duodenum, small intestine, and colon) may be controlled using a rapid whipstitch of 2-0 polypropylene. Complete transection of the bowel or segmental damage is controlled using a GIA stapler, often with resection of the injured segment. Before the patient is returned to the surgical intensive care unit (SICU), the abdomen must be temporarily closed. Originally, penetrating towel clips were used to approximate the skin; however, the ensuing bowel edema often produces a delayed abdominal compartment syndrome. Instead, the bowel is covered with a fenestrated subfascial sterile drape (45 x 60 em Steri-Drape 3M Health Care), and two Jackson-Pratt drains are placed along the fascial edges; this is then covered using an Ioban drape, which allows closed suction to control reperfusion-related ascitic fluid egress while providing adequate space for bowel expansion to prevent abdominal compartment syndrome.
Therapy for increased intracranial pressure (ICP) in a patient with a closed head injury is instituted when the ICP is greater than:
In patients with abnormal findings on CT scans and GCS scores of ≤8, intracranial pressure (ICP) should be monitored using fiberoptic intraparenchymal devices or intraventricular catheters. Although an ICP of 10 mm Hg is believed to be the upper limit of normal, therapy generally is not initiated until ICP is >20 mm Hg. Indications for operative intervention to remove space-occupying hematomas are based on the clot volume, amount of midline shift, location of the clot, GCS score, and ICP. A shift of >5 mm typically is considered an indication for evacuation, but this is not an absolute rule.
Cerebral perfusion pressure (CPP):
The goal of resuscitation and management in patients with head injuries is to avoid hypotension (SBP of <100 mm Hg) and hypoxia (partial pressure of arterial oxygen of <60 or arterial oxygen saturation of < 90). Attention, therefore, is focused on maintaining cerebral perfusion rather than merely lowering ICP. Resuscitation efforts aim for a euvolemic state and an SBP of >100 mm Hg. Cerebral perfusion pressure (CPP) is equal to the mean arterial pressure minus the ICP, with a target range of >50 mm Hg. CPP can be increased by either lowering ICP or raising mean arterial pressure. Sedation, osmotic diuresis, paralysis, ventricular drainage, and barbiturate coma are used in sequence, with coma induction being the last resort.
An 1 8-year-old man is admitted to the ED shortly after being involved in an automobile accident. He is in a coma (GCS = 7). His pulse is barely palpable at a rate of 140 beats per minute, and BP is 60/0. Breathing is rapid and shallow, aerating both lung fields. His abdomen is moderately distended with no audible peristalsis. There are closed fractures of the right forearm and the left lower leg. After rapid IV administration of 2 L of lactated Ringer solution in the upper extremities, his pulse is 130 and BP 70/0. The next immediate step should be to:
Ideally, a patient seriously injured in an automobile accident should undergo X-rays of the cervical spine, the chest, and the abdomen. When he has a GCS of 7, CT scans of the head are certainly desirable. If the chest X-ray shows a widened mediastinum, arch aortograms are indicated. However, this patient has had no response to a rapid fluid challenge, and if he is to survive, bleeding must be controlled immediately. The head injury, although severe, is not responsible for his hypotension and tachycardia. The most likely problem is uncontrolled abdominal hemorrhage. Immediate abdominal exploration offers the best chance for survival.
A 36-year-old patient arrives in the trauma bay with a stab wound to the left chest. After placement of a left thoracostomy tube and fluid resuscitation, his breathing is stable with BP 160/74 mm Hg and heart rate of 110 beats per minute. CT scanning reveals a descending thoracic pseudoaneurysm and no intracranial or intra-abdominal injury.
What is the most appropriate next step?
Descending thoracic aortic injuries may require urgent if not emergent intervention. However, operative intervention for intracranial or intra-abdominal hemorrhage or unstable pelvic fractures takes precedence. To prevent aortic rupture, pharmacologic therapy with a selective β1 antagonist, esmolol, should be instituted in the trauma bay, with a target SBP of <100 mm Hg and heart rate of <100 beats per minute. Endovascular stenting is now the mainstay of treatment, but open operative reconstruction is warranted, or necessary, in select patients. Endovascular techniques are particularly appropriate in patients who cannot tolerate single lung ventilation, patients older than 60 years who are at risk for cardiac decompensation with aortic clamping, or patients with uncontrolled intracranial hypertension.
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