Monothematic meeting of Sfar
The concept of damage control: Extending the paradigm in the prehospital settingLe concept de damage control : extension préhospitalière du paradigme,☆☆

https://doi.org/10.1016/j.annfar.2013.07.012Get rights and content

Abstract

Objective

The purpose of this review is to present the progressive extension of the concept of damage control resuscitation, focusing on the prehospital phase.

Article type

Review of the literature in Medline database over the past 10 years.

Data source

Medline database looking for articles published in English or in French between April 2002 and March 2013. Keywords used were: damage control resuscitation, trauma damage control, prehospital trauma, damage control surgery. Original articles were firstly selected. Editorials and reviews were secondly studied.

Data synthesis

The importance of early management of life-threatening injuries and rapid transport to trauma centers has been widely promulgated. Technical progress appears for external methods of hemostasis, with the development of handy tourniquets and hemostatic dressings, making the crucial control of external bleeding more simple, rapid and effective. Hypothermia is independently associated with increased risk of mortality, and appeared accessible to improvement of prehospital care. The impact of excessive fluid resuscitation appears negative. The interest of hypertonic saline is denied. The place of vasopressor such as norepinephrine in the early resuscitation is still under debate. The early use of tranexamic acid is promoted. Specific transfusion strategies are developed in the prehospital setting.

Conclusion

It is critical that both civilian and military practitioners involved in trauma continue to share experiences and constructive feedback. And it is mandatory now to perform well-designed prospective clinical trials in order to advance the topic.

Résumé

Objectif

L’objectif de cette mise au point était de présenter l’extension progressive du concept de damage control (DC), en s’intéressant plus spécifiquement à sa phase préhospitalière.

Type d’article

Revue de la littérature dans Medline au cours des dix dernières années.

Source des données

Base de données Medline à la recherche d’articles publiés en anglais ou en français, entre avril 2002 et mars 2013. Les mots-clés utilisés étaient : damage control resuscitation, trauma damage control, prehospital trauma, damage control surgery. Les articles originaux ont d’abord été sélectionnés. Les éditoriaux et les commentaires ont été par ailleurs étudiés.

Synthèse des données

L’importance de la prise en charge immédiate sur le terrain des traumatismes graves avec hémorragie et du transport rapide vers un centre de traumatologie est largement promulguée. Les méthodes d’hémostase externe connaissent des progrès techniques, avec le développement de garrots et de pansements hémostatiques opérationnels, pouvant autoriser un contrôle plus simple, rapide et efficace des saignements extériorisés. L’hypothermie est indépendamment associée à un risque accru de mortalité, mais est accessible à une prévention initiée dès la prise en charge sur le terrain. L’impact d’une réanimation liquidienne excessive semble négatif. L’intérêt de la solution saline hypertonique est dénié. La place de vasopresseur comme la noradrénaline au début de la réanimation est encore en débat. L’utilisation précoce d’acide tranexamique est promue. Des stratégies de transfusion spécifiques sont développées en milieu préhospitalier.

Conclusion

Il est essentiel que les praticiens civils et militaires impliqués dans les traumatismes continuent à partager les expériences et les commentaires constructifs. Et il nous faut maintenant réaliser des études cliniques prospectives bien conçues afin de faire avancer le sujet.

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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    ☆☆

    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.

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