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"

  1. Hypothermia: 34.8°C
  2. Acidosis: pH 7.18
  3. 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:

  1. Temporary packing of liver (perihepatic packing)
  2. Mesenteric bleeding controlled with sutures
  3. Abdomen left open - temporary abdominal closure (negative pressure wound therapy)
  4. 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:

  1. Warm: Active warming (Bair hugger, warm fluids, warm environment)
  2. Correct coagulopathy: Continue blood products, cryoprecipitate, correct acidosis
  3. 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

  1. Damage control surgery = abbreviated surgery to restore physiology
  2. Lethal triad (hypothermia, acidosis, coagulopathy) mandates damage control
  3. Principles: Control hemorrhage, control contamination, temporary closure
  4. Resuscitation in ICU to reverse physiologic insult
  5. Planned re-exploration when patient stabilized
  6. Staged definitive repairs when patient can tolerate
  7. 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

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