Annales Françaises d'Anesthésie et de Réanimation
Monothematic meeting of SfarThe concept of damage control: Extending the paradigm in the prehospital settingLe concept de damage control : extension préhospitalière du paradigme☆,☆☆
Introduction
Damage control was initially a naval tactic. It described actions like extinguishing local fires, stuffing mattresses into gaping holes, dogging down watertight doors to limit flooding and damage extension. These principles kept the ship afloat and allowed the ship to continue to fight, until a feasible plan for a definitive repair could be formulated.
Damage control surgery (DCS) was first used for patients with abdominal exsanguinating trauma in order to avoid prolonged operative times and prevent the onset of the lethal triad of coagulopathy, acidosis and hypothermia [1]. The concept of delay in definitive therapy while systems support is maintained is in fact the core principle of damage control strategy applied in hemorrhagic trauma. The quotation from Voltaire, “The art of medicine consists of amusing the patient while nature cures the disease”, sounds as an inspiration. In essence, damage control equates with abbreviated surgery and restoration of near normal physiology, in a staged approach to a life-threatening injury. DCS appeared to be a strong concept for the surgical teams, as far as it seemed efficient, and it spread firstly to intensive care units, secondly to the prehospital milieu. Hence, DCS was associated with a specific resuscitation strategy, transfusion tactic being the corner stone [2]. And the damage control resuscitation (DCR) concept, initially strictly limited to the hospital, was then prolonged in prehospital setting.
The purpose of this review is to present this progressive extension of the concept of DC in adult trauma patients, from surgery to intensive care and prehospital setting, so creating a continuum of care.
Section snippets
Definition
In 1983, Stone et al. published the first observation of intentional abbreviated laparotomy [3]. Coagulopathy was not as known as it is today but its severity was well received and the speed of hemostasis was only intended to allow survival. In 1993, Rotondo et al. formalized the principle of abbreviated laparotomy and proposed the term “Damage Control Laparotomy” in a retrospective study of 46 patients, with 22 survivors amongst the most seriously injured (vascular and more than two visceral
Setup of the associated critical care: damage control resuscitation
The term DCR refers to both the surgical techniques and the specific medical strategies. The underlying principle is to provide physiological optimization that will allow the best chance for recovery. Duchesne has recently reported improved outcomes by adding damage control resuscitation to damage control surgery (74% vs. 55%) [8].
Despite hemorrhage being a common problem, the optimal resuscitative strategy remains controversial and fosters vigorous debate. The immediate major objectives are
Principles
Analysis of epidemiologic data from large civilian trauma centers reveals that around half of the deaths occur before arrival in a hospital, mainly with massive blood loss [21]. Hemorrhage is still the leading cause of preventable death in combat casualties. The logical extension of this emphasis on early control of life-threatening injuries would be to initiate potentially life-saving maneuvers in the prehospital setting, with the expectation that providing such basic interventions as soon as
Conclusion
Following better understanding of traumatic coagulopathy and data from the military setting, there has been a marked shift in the practice of trauma resuscitation over the last decade towards damage control resuscitation, which can be seen as a goal-directed therapy to combat acidosis, hypothermia, coagulopathy and hypoperfusion. DCS appeared at first to be a strong concept for the surgical teams, and then it spread to the intensive care units and to the prehospital milieu. The DC resuscitation
Disclosure of interest
The authors declare that they have no conflicts of interest concerning this article.
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Medical response to major disasters
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Article presented at Monothematic meeting of Sfar (Société française d’anesthésie et de réanimation): “Severe trauma: the first 24 hours”, Paris, May 29th, 2013.
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This article is published under the responsibility of the Scientific Committee of the “Journée Monothématique 2013” de la Sfar (http://www.jmtsfar.com). The editorial board of the Annales françaises d’anesthésie et de réanimation was not involved in the conception and validation of its content.