The resuscitation period lets any physiologic derangements be reversed to give the best outcome for patient care. The first is controlling hemorrhage followed by contamination control, abdominal packing, and placement of a temporary closure device. If unable to oxygenate with conventinal ventilation, at Parkland Memorial Hospital we use the Volume Diffuse Respirator (VDR) as a salvage therapy. Gifford and colleagues provided one of the only studies to characterize longer-term extremity outcomes following the use of temporary vascular shunts.  Surgeons can also apply manual pressure, perform hepatic packing, or even plugging penetrating wounds. First is hemorrhage control, second is contamination control, third is evaluation or diagnosis, and fourth is reconstruction. In fact, data suggests that around 25% of patients arrive having coagulopathy. This lets granulation occur over a few weeks, with the subsequent ability to place a split-thickness skin graft (STSG) on top for coverage. Initial resuscitation should begin in the emergency department and continue in the operating room following correction of deficit and using a massive transfusion program as indicated. Each injury must be evaluated on a case-by-case basis, as no single algorithm is adequate to predict management in these cases. Decision to perform DCS. It is important to not only pack areas of injury but also pack areas of surgical dissection.  For trauma teams to systematically and efficiently deliver blood products institutions have created protocols that allow for this. Author information: (1)Foothills Medical Centre, University of Calgary, Calgary, Alberta, Canada. Massive transfusion (defined as receiving greater than or equal to 10 units of packed red blood cells with a 24-hour period) is required in up to 5% of civilian trauma patients that arrive severely injured. Once the abdominal packs are removed the next step is to re-explore the abdomen allowing for the identification of potentially missed injuries during the initial laparotomy and re-evaluating the prior injuries. If bowel edema prevents this, several techniques (e.g., Wittman patch) can be employed to help reapproximate fascial edges in stages. Work is being undertaken on product ratios26,27 and the use of novel compounds to reduce this reliance, such as lyophilized fibrinogen and platelets.28, James A Judson, Li C Hsee, in Oh's Intensive Care Manual (Seventh Edition), 2014, In penetrating trauma, there is some evidence that extensive fluid resuscitation prior to haemostasis may be detrimental, presumably because of higher blood pressure, displacement of blood clot and dilution of coagulation factors.22,23. Even apparently clean wounds should not be closed before 4–5 days. Early recognition of significant physiologic derangement and the need for DCS are critical as inability to correct pH >7.21 and PTT >70 is associated with near certain mortality. Certain pitfalls have also become evident, one of which is the potential to develop abdominal compartment syndrome (ACS). Lucas and Ledgerwood described the principle in a series of patients. In a report from Operation Iraqi Freedom (OIF), Rasmussen et al described a 1-year experience of 126 extremity vascular injuries, in which 30 temporary vascular shunts were utilized in the management of vascular injury. Additionally numerous retrospective studies have shown the effectiveness of vein as a conduit in extremity trauma. In most experiences, harvesting and preparation of the saphenous vein requires 15 to 30 minutes; and this can be longer if difficulties are encountered with a dual saphenous system or if one includes wound closure in the time estimate. Once this is complete the abdomen should be packed. Damage Control Surgery Brett H. Waibel Michael F. Rotondo I. Vessels that are able to be ligated should, and one should consider shunting other vessels that do not fall into this category. The damage control (DC) laparotomy is therefore not an operation of last resort; rather, it is a well thought-out stage on a continuum of care which prioritizes the restoration of physiologic normality and homeostasis above definitive organ repair and anatomic reconstruction.  This extrapolation allowed for the first article in 1993 by Rotondo and Schwab specifically adapting the term “damage control”. The following goes through the different phases to illustrate, step by step, how one might approach this. Rather than representing a deterioration in technique or care, this likely reflects maintenance and transport of evermore severely injured patients to the hospital phase of management.7 Ongoing changes in resuscitation strategies, with a greater emphasis on matched red blood cell to plasma ratios and decreased crystalloid volumes, may prove especially beneficial in low-pressure venous injuries. Copyright © 2021 Elsevier B.V. or its licensors or contributors. Preoperative decision to perform a DCS procedure is frequently made in patients with multisystem trauma. Staged physiologic restoration and damage control surgery.  Next is the development of an entero-atmospheric fistula, which ranges from 2 to 25%. History and Evolution of Damage Control The foundation of damage control surgery (DCS) focuses on exsanguinating truncal trauma. This specifically relates to factors such as acidosis, coagulopathy, and hypothermia (lethal triad) that many of these critically ill patients develop. This approach emerged after his observation that early death following trauma was associated with severe metabolic and physiologic derangements following severe exsanguinating injuries. The bowel should be separated from laparotomy pads. Nonoperative treatment can be the first-line intervention for stable patients with low- or medium-grade liver, spleen, and kidney injuries. In this report, shunts were used as damage control adjuncts to either facilitate casualty evacuation or to allow perfusion while other life-threatening injuries were managed. The underpinning for damage control is that a traditional operative approach risks physiologic exhaustion, and an abbreviated initial operation controlling only hemorrhage and contamination and … Such evidence mentoring to empower non-physicians to address junctional and torso hemorrhage control in austere environments mandates first... 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