Damage control strategies in the management of acute injury

Original Article


Traumatic injury is the leading cause of death worldwide. The rapid evaluation and correction of injuries in these patients is paramount to preventing uncontrolled decompensation and death. Damage control strategies are a compendium of techniques refined over decades of surgical care that focus on the rapid correction of deranged physiology, control of contamination and blood loss, and resuscitation of critical patients. Damage control resuscitation (DCR) focuses on the replacement of lost blood volume in a manner mimicking whole blood, control of crystalloid administration, and permissive hypotension. Damage control laparotomy controls gastrointestinal contamination and bleeding in the operative suite, allowing rapid egress to the intensive care unit for ongoing resuscitation. Pelvic packing, an adjunct to DCR, provides a means to control hemorrhage from severe pelvic fractures. Temporary vascular shunts restore perfusion, while resuscitation and reconstruction are ongoing. Taken together, these strategies provide the trauma surgeon with a powerful arsenal to preserve life in the transition from injury to the shock trauma room to the intensive care unit.


Damage control Hemorrhage Resuscitation 


  1. 1.
    Centers for Disease Control and Prevention (CDC). Injury prevention & control: worldwide injuries and violence. 2013. http://www.cdc.gov/injury/global/. Accessed 12 Dec 2013.
  2. 2.
    Campion EM, Pritts TA, Dorlac WC, et al. Implementation of a military-derived damage-control resuscitation strategy in a civilian trauma center decreases acute hypoxia in massively transfused patients. J Trauma Acute Care Surg. 2013;75(2 Suppl 2):S221–7.PubMedCrossRefGoogle Scholar
  3. 3.
    Savage SA, Zarzaur BL, Croce MA, et al. Redefining massive transfusion when every second counts. J Trauma Acute Care Surg. 2013;74(2):396–400.PubMedCrossRefGoogle Scholar
  4. 4.
    Dua A, Patel B, Kragh JF Jr, et al. Long-term follow-up and amputation-free survival in 497 casualties with combat-related vascular injuries and damage-control resuscitation. J Trauma Acute Care Surg. 2012;73(6):1517–24.PubMedCrossRefGoogle Scholar
  5. 5.
    Kauvar DS, Holcomb JB, Norris GC, et al. Fresh whole blood transfusion: a controversial military practice. J Trauma. 2006;61(1):181–4.PubMedCrossRefGoogle Scholar
  6. 6.
    Kutcher ME, Kornblith LZ, Narayan R, et al. A paradigm shift in trauma resuscitation: evaluation of evolving massive transfusion practices. JAMA Surg. 2013;148(9):834–40.PubMedCrossRefGoogle Scholar
  7. 7.
    Cotton BA, Reddy N, Hatch QM, et al. Damage control resuscitation is associated with a reduction in resuscitation volumes and improvement in survival in 390 damage control laparotomy patients. Ann Surg. 2011;254(4):598–605.PubMedCrossRefGoogle Scholar
  8. 8.
    Duchesne JC, Hunt JP, Wahl G, et al. Review of current blood transfusions strategies in a mature level I trauma center: were we wrong for the last 60 years? J Trauma. 2008;65:272–6.PubMedCrossRefGoogle Scholar
  9. 9.
    Holcomb JB, Wade CE, Michalek JE, et al. Increased plasma and platelet to red blood cell ratios improves outcome in 466 massively transfused civilian trauma patients. Ann Surg. 2008;248:447–58.PubMedGoogle Scholar
  10. 10.
    Brown LM, Aro SO, Cohen MJ, et al. A high fresh frozen plasma: packed red blood cell transfusion ratio decreases mortality in all massively transfused trauma patients regardless of admission international normalized ratio. J Trauma. 2011;71(2 Suppl 3):S358–63.PubMedCrossRefGoogle Scholar
  11. 11.
    Pati S, Matijevic N, Doursout MF, et al. Protective effects of fresh frozen plasma on vascular endothelial permeability, coagulation, and resuscitation after hemorrhagic shock are time dependent and diminish between days 0 and 5 after thaw. J Trauma. 2010;69(Suppl 1):S55–63.PubMedCentralPubMedCrossRefGoogle Scholar
  12. 12.
    Kozar RA, Peng Z, Zhang R, et al. Plasma restoration of endothelial glycocalyx in a rodent model of hemorrhagic shock. Anesth Analg. 2011;112(6):1289–95.PubMedCentralPubMedCrossRefGoogle Scholar
  13. 13.
    Eder AF, Herron R, Strupp A, et al. Transfusion-related acute lung injury surveillance (2003–2005) and the potential impact of the selective use of plasma from male donors in the American Red Cross. Transfusion. 2007;47:599–607.PubMedCrossRefGoogle Scholar
  14. 14.
    Chapman CE, Stainsby D, Jones H, et al. Ten years of hemovigilance reports of transfusion-related acute lung injury in the United Kingdom and the impact of preferential use of male donor plasma. Transfusion. 2009;49:440–52.PubMedCrossRefGoogle Scholar
  15. 15.
    Bickell WH, Wall MJ Jr, Pepe PE, et al. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. N Engl J Med. 1994;331:1105–9.PubMedCrossRefGoogle Scholar
  16. 16.
    Morrison CA, Carrick MM, Norman MA, et al. Hypotensive resuscitation strategy reduces transfusion requirements and severe postoperative coagulopathy in trauma patients with hemorrhagic shock: preliminary results of a randomized controlled trial. J Trauma. 2011;70(3):652–63.PubMedCrossRefGoogle Scholar
  17. 17.
    Alam HB, Velmahos GC. New trends in resuscitation. Curr Probl Surg. 2011;48:531–64.PubMedCentralPubMedCrossRefGoogle Scholar
  18. 18.
    Ley EJ, Clond MA, Srour MK, et al. Emergency department crystalloid resuscitation of 1.5 L or more is associated with increased mortality in elderly and nonelderly trauma patients. J Trauma. 2011;70:398–400.PubMedCrossRefGoogle Scholar
  19. 19.
    Makley AT, Goodman MD, Belizaire RM, et al. Damage control resuscitation decreases systemic inflammation after hemorrhage. J Surg Res. 2012;175:e75–82.PubMedCentralPubMedCrossRefGoogle Scholar
  20. 20.
    Schnüriger B, Inaba K, Wu T, et al. Crystalloids after primary colon resection and anastomosis at initial trauma laparotomy: excessive volumes are associated with anastomotic leakage. J Trauma. 2011;70:603–10.PubMedCrossRefGoogle Scholar
  21. 21.
    Stone HH, Strom PR, Mullins RJ. Management of the major coagulopathy with onset during laparotomy. Ann Surg. 1983;197:532–5.PubMedCentralPubMedCrossRefGoogle Scholar
  22. 22.
    Mohr AM, Asensio JA, García-Núñez LM, et al. Guidelines for the institution of damage control in trauma patients. ITACCS. 2005;Fall:1−5.Google Scholar
  23. 23.
    Moore EE. Staged laparotomy for the hypothermia, acidosis, and coagulopathy syndrome. Am Surg. 1996;172(5):405–10.CrossRefGoogle Scholar
  24. 24.
    Sharp KW, Locicero RJ. Abdominal packing for surgically uncontrollable hemorrhage. Ann Surg. 1992;215:467–74.PubMedCentralPubMedCrossRefGoogle Scholar
  25. 25.
    Cosgriff N, Moore EE, Sauaia A, et al. Predicting life-threatening coagulopathy in the massively transfused trauma patient: hypothermia and acidoses revisited. J Trauma. 1997;42:857–61.PubMedCrossRefGoogle Scholar
  26. 26.
    Asensio JA, McDuffie L, Petrone P, et al. Reliable variables in the exsanguinated patient which indicate damage control and predict outcome. Am J Surg. 2001;182:743–51.PubMedCrossRefGoogle Scholar
  27. 27.
    Burch JM, Ortiz VB, Richardson RJ, et al. Abbreviated laparotomy and planned reoperation for critically injured patients. Ann Surg. 1992;215:476–83.PubMedCentralPubMedCrossRefGoogle Scholar
  28. 28.
    Asensio JA, Petrone P, Roldán G, et al. Has evolution in awareness of guidelines for institution of damage control improved outcome in the management of the posttraumatic open abdomen? Arch Surg. 2004;139:209–15.PubMedCrossRefGoogle Scholar
  29. 29.
    Fabian TC. Damage control in trauma: laparotomy wound management acute to chronic. Surg Clin North Am. 2007;87:73–93.PubMedCrossRefGoogle Scholar
  30. 30.
    Cannon JW. Damage control: a balancing act. JAMA Surg. 2013;148(10):955.PubMedCrossRefGoogle Scholar
  31. 31.
    Bradley MJ, DuBose JJ, Scalea TM, et al. Independent predictors of enteric fistula and abdominal sepsis after damage control laparotomy: results from the prospective AAST open abdomen registry. JAMA Surg. 2013;148(10):947–54.PubMedCrossRefGoogle Scholar
  32. 32.
    Boele van Hensbroek P, Wind J, Dijkgraaf MG, et al. Temporary closure of the open abdomen: a systematic review on delayed primary fascial closure in patients with an open abdomen. World J Surg. 2009;33(2):199–207.PubMedCentralPubMedCrossRefGoogle Scholar
  33. 33.
    Burlew CC, Moore EE, Smith WR, et al. Preperitoneal pelvic packing/external fixation with secondary angioembolization: optimal care for life-threatening hemorrhage from unstable pelvic fractures. J Am Coll Surg. 2011;212:628–37.PubMedCrossRefGoogle Scholar
  34. 34.
    Tai DKC, Li WH, Lee KY, et al. Retroperitoneal pelvic packing in the management of hemodynamically unstable pelvic fractures: a Level I trauma center experience. J Trauma. 2011;71(4):E79–86.PubMedCrossRefGoogle Scholar
  35. 35.
    Tosounidis TI, Giannoudis PV. Pelvic fractures presenting with haemodynamic instability: treatment options and outcomes. Surgeon. 2013;11:344–51.PubMedCrossRefGoogle Scholar
  36. 36.
    Pohlemann T, Gänsslen A, Bosch U, et al. The technique of packing for control of hemorrhage in complex pelvic fractures. Tech Orthop. 1994;9:267–70.CrossRefGoogle Scholar
  37. 37.
    Ertel W, Keel M, Eid K, et al. Control of severe hemorrhage using C-clamp and pelvic packing in multiply injured patients with pelvic ring disruption. J Orthop Trauma. 2001;15:468–74.PubMedCrossRefGoogle Scholar
  38. 38.
    Sauaia A, Moore FA, Moore EE, et al. Epidemiology of trauma deaths: a reassessment. J Trauma. 1995;38(2):185–93.PubMedCrossRefGoogle Scholar
  39. 39.
    Kragh JF Jr, Murphy C, Dubick MA, et al. New tourniquet device concepts for battlefield hemorrhage control. US Army Med Dep J. 2011;April–June:38−48.Google Scholar
  40. 40.
    Rasmussen TE, DuBose JJ, Asensio JA, et al. Tourniquets, vascular shunts, and endovascular technologies: esoteric or essential? A report from the 2011 AAST Military Liaison Panel. J Trauma Acute Care Surg. 2012;73(1):282–5.PubMedCrossRefGoogle Scholar
  41. 41.
    Hancock H, Rasmussen TE, Walker AJ, et al. History of temporary intravascular shunts in the management of vascular injury. J Vasc Surg. 2010;52(5):1405–9.PubMedCrossRefGoogle Scholar
  42. 42.
    Rasmussen TE, Clouse WD, Jenkins DH, et al. The use of temporary vascular shunts as a damage control adjunct in the management of wartime vascular injury. J Trauma. 2006;61(1):8–15.PubMedCrossRefGoogle Scholar
  43. 43.
    Subramanian A, Vercruysse G, Dente C, et al. A decade’s experience with temporary intravascular shunts at a civilian Level I Trauma Center. J Trauma. 2008;65(2):316–26.PubMedCrossRefGoogle Scholar
  44. 44.
    Taller J, Kamdar JP, Greene JA, et al. Temporary vascular shunts as initial treatment of proximal extremity vascular injuries during combat operations: the new standard of care at Echelon II facilities? J Trauma. 2008;65(3):595–603.PubMedCrossRefGoogle Scholar
  45. 45.
    Borut LT, Acosta CJ, Tadlock LC, et al. The use of temporary vascular shunts in military extremity wounds: a preliminary outcome analysis with 2-year follow-up. J Trauma. 2010;69(1):174–8.PubMedCrossRefGoogle Scholar
  46. 46.
    Stannard A, Eliason JL, Rasmussen TE. Resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct for hemorrhagic shock. J Trauma. 2011;71(6):1869–72.PubMedCrossRefGoogle Scholar
  47. 47.
    Martinelli T, Thony F, Decléty P, et al. Intra-aortic balloon occlusion to salvage patients with life-threatening hemorrhagic shocks from pelvic fractures. J Trauma. 2010;68(4):942–8.PubMedGoogle Scholar
  48. 48.
    White JM, Cannon JW, Stannard A, et al. Endovascular balloon occlusion of the aorta is superior to resuscitative thoracotomy with aortic clamping in a porcine model of hemorrhagic shock. Surgery. 2011;150(3):400–9.PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2014

Authors and Affiliations

  1. 1.University of Tennessee Health Sciences CenterMemphisUSA

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