Damage control surgery--physiopathological benchmarks.

The following article, submitted in two complementary parts deals with an important and also modern concept developed under the name of damage-control surgery. Physiopathologically, the multiple injured patient is characterised by the probable, not just possible, appearance of the "blood's vicious cycle" of hypocoagulability, hypothermia and acidosis with death as a result. The first part of the article addresses the changes that are the reasons and the basis for applying damage-control surgery. Hypothermia is a direct result of trauma and patient's exposure to it but can also emerge throughout transportation, evaluation, emergency and surgical procedures to which the patient undergoes. Surgical procedures are directly a source that decreases the core temperature. While blood losses accompany trauma for certain and affect clot formation, the patient's coagulation system is impaired by these losses and the dysfunction is further enhanced by hypotermia, different mechanisms being involved. The third lethal component is acidosis. While being at first metabolically produced because of tissular injury, it is further enhanced by the other two elements. From a practical point of view, hypothermia and hypocoagulability can be though, more theoretically addressed, acidosis is more difficult to correct. As fav as the emergency specialist is concerned for the moment, the best solution to deal with this deadly triad is to prevent it. Damage-control surgery is just one type of measure in the process of prevention.

Damage control surgery--new concept or reenacting of a classical idea?

Damage-control surgery is an example of a paradigm shift. The term is borrowed from naval teminology and means gaining the initial control of a damaged ship. Because of the lethal triad the polytrauma patient is at a grave risk. The classical concept of surgically solving all the patient's injuries in the first moment was even theoretically incorrect as a multiple injured patient is a critical patient with depleted reserves. As such, complex procedures were doomed from this point of view. The concept of damage-control surgery emerged in 1992. The core idea was that as minimal as possible had to be done in these critical patients in the first phase, meaning temporary control of a hemorrhage and simple measures for stopping contamination. After 24-48 hours in the ICU, in which time the physiological disturbances were corrected, a further intervention is perfomed for definitively treating the injuries. Further refinements consider five stages and not three in damage-control surgery. The bright side of the concept is an up to 70% survivability rate but with a higher risk of complications, mostly due to the policy of temporary closing the abdomen and sepsis.