General Surgery · Year 3 · from General Surgery
Case 3: Damage Control Surgery for Severe Trauma
Patient Demographics
- Age: 35 years
- Sex: Female
- Occupation: Nurse
Chief Complaint
Brought by helicopter EMS after high-speed motor vehicle collision
History of Present Illness
The patient was the unrestrained driver in a single-vehicle rollover at highway speed. She was found partially ejected from the vehicle with significant deformity to the front of the car. She was unresponsive at the scene. GCS was 6 (E1V2M3). She was intubated in the field.
Prehospital Information
- GCS 6 → intubated
- BP 70/40 (after 2L crystalloid)
- Bilateral femur deformities
- Massive external hemorrhage controlled with tourniquets
Primary Survey (on arrival)
- A: Intubated, tube confirmed
- B: Bilateral breath sounds, clear
- C: BP 72/40, HR 148, massive transfusion already initiated
- D: GCS 3T (sedated), pupils 3mm bilateral and reactive
- E: Multiple injuries: open book pelvis, bilateral femur fractures, large scalp laceration
FAST Examination
- Positive: Large amount of free fluid in all quadrants
- Pericardium: No effusion
Resuscitation
- Massive transfusion protocol ongoing
- Blood products: PRBCs, FFP, platelets (1:1:1)
- Calcium replacement (for citrate toxicity)
- Pelvic binder applied
Laboratory Results
- pH: 7.18 (acidosis)
- Lactate: 8.4 mmol/L
- Base deficit: -12
- Temperature: 34.8°C (hypothermia)
- INR: 1.8 (coagulopathy)
- Fibrinogen: 120 mg/dL (low)
The "Lethal Triad"
- Hypothermia: 34.8°C
- Acidosis: pH 7.18
- Coagulopathy: INR 1.8
Decision: Damage Control Surgery
Patient meets criteria for damage control approach:
- Severe physiologic derangement
- Multiple injuries
- Lethal triad developing
- NOT candidate for definitive repair
Damage Control Laparotomy
Findings:
- 3L hemoperitoneum
- Grade V liver laceration (involving retrohepatic vena cava area)
- Mesenteric injury with active bleeding
- No hollow viscus injury identified
Damage Control Procedures:
- Temporary packing of liver (perihepatic packing)
- Mesenteric bleeding controlled with sutures
- Abdomen left open - temporary abdominal closure (negative pressure wound therapy)
- Total OR time: 35 minutes
Goal: Stop hemorrhage, prevent contamination, restore perfusion, LEAVE THE OR
Orthopedic Intervention
- Bilateral femur external fixation (temporary)
- Pelvic binder continued
ICU Resuscitation Phase
Goals:
- Warm: Active warming (Bair hugger, warm fluids, warm environment)
- Correct coagulopathy: Continue blood products, cryoprecipitate, correct acidosis
- Optimize perfusion: Goal-directed resuscitation, vasopressors as needed
Progress Over 48 Hours
- Temperature: 36.8°C
- pH: 7.38
- INR: 1.1
- Lactate: 1.6 mmol/L
- Hemodynamically stable on minimal vasopressors
Planned Re-Exploration (48 hours)
Take-back laparotomy:
- Packing removed carefully
- Liver hemostasis achieved (bleeding stopped)
- Mesentery healing
- Bowel viable
- Abdomen closed (delayed primary closure)
Subsequent Operations
- Day 5: Definitive femur fixation (intramedullary nails)
- Day 7: Pelvic fixation
Hospital Course
- ICU x 10 days
- Transferred to floor
- Rehabilitation facility transfer Day 21
Teaching Points
- Damage control surgery = abbreviated surgery to restore physiology
- Lethal triad (hypothermia, acidosis, coagulopathy) mandates damage control
- Principles: Control hemorrhage, control contamination, temporary closure
- Resuscitation in ICU to reverse physiologic insult
- Planned re-exploration when patient stabilized
- Staged definitive repairs when patient can tolerate
- Damage control resuscitation parallels damage control surgery
Clinical Image
Image Description: Temporary abdominal closure with negative pressure wound therapy dressing following damage control laparotomy. The open abdomen allows for re-exploration and prevents abdominal compartment syndrome while the patient undergoes physiologic resuscitation.
Attribution: Image from Wikimedia Commons. Source: https://commons.wikimedia.org/wiki/Category:Trauma_surgery