Trauma Surgery

How to Win a Gun Fight with a Knife

When you can’t control what’s happening, challenge yourself to control the way you respond to what’s happening. That’s where your power is.

Anonymous

You see, in this world, there are two kinds of people, my friend – those with loaded guns, and those who dig. You dig.

Clint Eastwood
The Damage Control Principle

Sometimes things get really bad… And you may find yourself wondering how to get out of it.

You know that your future choices will define only two possible outcomes: life or death…

You cannot flee, because it will end with the patient’s certain death… So, the only other option available is to fight… But how?!

In the Navy, when a ship has sustained damages and it’s in peril to sink, the emergency control of this situation is mandatory. The basic principle is to limit the damaging effects of the harming processes. All the actions required to avoid the sinking of the ship are defined as damage control. At the end of this process, the ship won’t be as good as new, but it will be good enough to not fall apart and to continue floating.

If this principle is applied to surgery… that’s the Damage Control Surgery (DCS)… aka “the only way to bring a patient back from the dead”.

However, the term “Damage Control” can be applied to many other branches of the medical world, such as ICU and ortho…

The basic principle is always the same: to do the less to obtain the most.

You have to consider that a traumatized patient can be very delicate, even if he/she is young. Moreover, a long and complex surgical procedure is an important source of stress for the human body. These two elements (i.e. a traumatized patient, and a long and complex surgical procedure) should be interconnected very carefully, since the “wrong” operation in the “wrong” patient may lead the guy to the otherworld.

Therefore, in the case of an unstable trauma patient, the correct sequence of events should be:

  1. Damage control resuscitation
  2. Damage control surgery
  3. Restore physiology in the ICU
  4. Definitive surgery and abdominal closure

Remember that you cannot proceed to the fourth point (i.e. definitive surgery) if the patient’s physiology has not been restored yet. On this occasion, relook laparotomies with other damage control surgery procedures may be undertaken.

Ok now, let’s start with a simple trauma case…

A – 47 yo male

T – 8.47 PM

M – Motor-vehicle accident (car vs. truck), patient’s the car driver (driver’s on the left side of the car)

I – Left chest pain, diffuse abdominal pain

S – BP 98/69; HR 119 bpm; SatO2 96% in room air; RR 26 breaths per minute; Temp 36.2 °C; GCS 14/15

T – 2x 18G IV-lines, 1000 mL Ringer Acetate, fentanyl 50+50 mcg, oxygen supply

Primary Survey:

A – Airways patent, no C-spine tenderness

B – Pain on the left chest, reduced lung sounds on the left side, ICD inserted (drained air and 350 mL blood), RR 24 and SatO2 98% on oxygen (FiO2 35%) after drainage

C – Diffuse abdominal tenderness, seatbelt signs, pelvis stable, BP 85/54, HR 123

D – GCS 12/15, pupils equal and reactive to light, no lateralizing signs

E – Logroll negative, Temp 35.7°C, active external warming, blood from the urinary catheter

E-FAST – left pneumohemothorax, abdominal free fluid (perihepatic, perisplenic and in the pelvis)

CXR & PXR – left pneumothorax, ICD in place

ABG – pH 7.30, HCO3 17.4, pO2 87 mmHg, pCO2 34 mmHg, Hb 8.7 g/dL, Lac 32 mmol/L, BE -18.7 mmol/L

The question now is: how to proceed? CT scan? OR?

The Damage Control Surgery Principles

Damage Control Surgery has only two simple principles: stop the bleeding and minimize the contamination… or, in other words, turn off the tap.

Some authors advocate the use of some features as indicators of when DCS should be applied:

  1. Initial body temperature <35°C
  2. Initial acid-base status
    • pH <7.2
    • Base deficit <-15 mmol/L
    • Serum lactate >5 mmol/L
  3. The onset of coagulopathy, defined as INR and/or partial thromboplastin time >50% of normal
  4. Massive transfusion (i.e. ≥10 blood units in 24 hours)
  5. Use of high-dose vasopressors (e.g. norepinephrine)
  6. Extensive injuries

The truth is that you must use the DCS when the patient cannot sustain any further insult (e.g. long surgical procedures, surgical complications, etc.)… and this decision must rely upon your personal medical judgment.

The choice of applying the DCS principles can be done preoperatively or intraoperatively. Usually, you suspect preoperatively that a patient may need DCS and, intraoperatively, once you’ve opened and explored his/her abdomen, and evaluated the grade of injuries, you decide whether to proceed with the DCS or to change the approach to definitive surgery.

Beware that if you suspect DCS may be needed, the surgical operation must not be delayed by CT scans, MRIs, or whatsoever… Surgery must be started ASAP!!!

Now, how to address the question proposed in the clinical scenario? How to proceed with our patient? CT scan or OR?

The patient is clearly hemodynamically unstable, and he is bleeding inside the abdomen. If we decide to take him to CT scan, he will bleed more and more until he will run out of blood… and this is not a fortunate event…

Therefore, the only possible answer must be the OR. It is true that you don’t know where he is bleeding from, but it is more important to save the patient than to understand which is his bleeding source. The patient is going to need the OR anyway.

Remember that when in doubt you have to ask yourself: will this change my plan?

If it does not, don’t do that!!!

Damage Control Surgery in Practice

As stated before, the correct surgical approach to trauma patients should include some steps:

  1. Trauma laparotomy (i.e. access to the abdominal cavity)
  2. Exposure
  3. Temporary bleeding control
  4. Systematic exploration and injury evaluation
  5. Surgical procedure – definitive surgery vs. DCS

This sequence must be followed in both hemodynamically stable and unstable patients.

Once you have opted for DCS, you need to address the two main sources of harm: contamination and bleeding.

Contamination can be managed in two ways:

  • Small single hole: cobbled;
  • Multiple holes in a short bowel segment, or a large single hole: clip & drop (i.e. resection of the bowel involved without anastomosis).

On the other hand, there are multiple solutions to the bleeding problem:

  • Packing: it is the first method used to achieve bleeding control at the beginning of the surgical procedure. Packing is most useful in some circumstances, such as hepatic bleeding, pelvic bleeding (along with the pelvic binder), and diffuse bleeding secondary to the onset of coagulopathy;
  • Balloon tamponade: useful in case of a penetrating liver or pelvic wound actively bleeding. You may use a home-made balloon, a Foley catheter, or a Sengstaken-Blackemore tube;
  • Vessel ligation: most veins and some arteries can be safely ligated;
  • Splenectomy: remember that packing the spleen is only a temporary maneuver done at the beginning of the emergency laparotomy. The DCS procedure in a bleeding spleen is splenectomy.

Another possible problem to solve during DCS is ischemia secondary to a vessel injury. The procedure of choice in this setting is an external vascular shunt.

Remember that after DCS, the abdomen must be left open, possibly dressed with an industrial or home-made negative pressure wound therapy device (e.g. VAC™ Therapy, ABTHERA™ Therapy, Barker’s technique…).

Ok… Now, let’s see how to manage our patient…

The patient was brought in the OR, tubed, and draped properly (chest, abdomen, and groin exposed).

Before starting the operation, the anesthetist tells you the patient is unstable, and he has started norepinephrine infusion.

You perform the emergency laparotomy, and once you have access to the abdominal cavity, you find a lot of blood. You remove the clots with your hands and pack the abdomen. Then you remove systematically the abdominal pads and explore the abdomen. After the exploration, you have found the following injuries: a major splenic laceration, a bleeding injury from the left lobe of the liver, a big laceration opening a mid-small bowel loop in two, and a bladder perforation.

At this point, there’s no other option than DCS. Therefore, you have to proceed with: splenectomy, segmental small bowel resection without anastomosis (i.e. clip & drop), primary repair of the bladder perforation, and packing of the liver. You have to leave the abdomen open, using a negative pressure wound therapy device.

Operating time: 40 min.

After the operation, the patient can go to the ICU to be adequately resuscitated before returning to the OR for the second look.

We hope you have understood the importance of the DCS principle. Trust us when we say that this principle can act as a watershed between the patients’ life and death. Sometimes, in these situations, the less is more and the more is less…

Remember that the DCS is not a collection of surgical techniques you can study… It is a philosophical concept, a mindset, a way of thinking… And this makes it more difficult to learn by experienced elective surgeons.

Peace…

References
  • Moore EE, et al. Trauma. 8th Ed. New York, NY: McGraw-Hill Education; 2018.
  • Hirshberg A, et al. Top Knife: the art & craft in trauma surgery. Shrewsbury, UK: Tfm Pub Ltd; 2015.
  • Boffard KD. Manual of Definitive Surgical Trauma Care. 5th Ed. Boca Raton, FL: CRC Press; 2019.
How to Cite This Post

Bellio G, Marrano E. How to Win a Gun Fight with a Knife. Surgical Pizza. Published on September 27, 2020. Accessed on September 18, 2021. Available at [https://surgicalpizza.org/trauma/how-to-win-a-gun-fight-with-a-knife/].

4 Comments

Leave a Reply

Your email address will not be published. Required fields are marked *