Damage control surgery: are we losing control over indications?

THE MANAGEMENT OF THE VICTIMS WITH GUNSHOT WOUNDS OF THE EXTREMITIES WITH EXTENSIVE DEFECTS OF THE SOFT TISSUES AT THE LEVEL OF QUALIFIED MEDICAL CARE. CASE-SERIES

OBJECTIVE

The aim: To highlight the original experience of diagnosis and treatment of patients with gunshot wounds of the extremities with extensive defects of the soft tissues.

PATIENTS AND METHODS

Materials and methods: The total number of treated patients with massive gunshot wounds from February 2022 to March 2023 was 60 males. Basic labo¬ratory tests, X-rays of the affected limbs were performed to all patients. USS of the vessels with color Doppler was performed to those casualties who had no peripheral pulses on the wounded extremity. All injured persons underwent wound debridement and fasciotomy on the day of admission, 8 more casualties underwent surgical interventions on the major vessels and nerves.

RESULTS

Results: Good treatment outcomes for patients with extensive soft tissue injury were achieved by early surgical intervention to remove non-viable tissue. Limb preservation was achieved in 98.3% of cases.

CONCLUSION

Conclusions: The study's conclusion emphasizes the importance of a multidisciplinary approach to treating patients with gunshot wounds to the limbs with extensive soft tissue injury. Early surgical interventions with the removal of non-viable tissues are necessary for good outcomes. Revascularization of the affected limb is essential in case of major vessel injury if there is no thread to the life.

Management of Hemorrhagic Shock: Physiology Approach, Timing and Strategies

Hemorrhagic shock (HS) management is based on a timely, rapid, definitive source control of bleeding/s and on blood loss replacement. Stopping the hemorrhage from progressing from any named and visible vessel is the main stem fundamental praxis of efficacy and effectiveness and an essential, obligatory, life-saving step. Blood loss replacement serves the purpose of preventing ischemia/reperfusion toxemia and optimizing tissue oxygenation and microcirculation dynamics. The "physiological classification of HS" dictates the timely management and suits the 'titrated hypotensive resuscitation' tactics and the 'damage control surgery' strategy. In any hypotensive but not yet critical shock, the body's response to a fluid load test determines the cut-off point between compensation and progression between the time for adopting conservative treatment and preparing for surgery or rushing to the theater for rapid bleeding source control. Up to 20% of the total blood volume is given to refill the unstressed venous return volume. In any critical level of shock where, ab initio, the patient manifests signs indicating critical physiology and impending cardiac arrest or cardiovascular accident, the balance between the life-saving reflexes stretched to the maximum and the insufficient distal perfusion (blood, oxygen, and substrates) remains in a liable and delicate equilibrium, susceptible to any minimal change or interfering variable. In a cardiac arrest by exsanguination, the core of the physiological issue remains the rapid restoration of a sufficient venous return, allowing the heart to pump it back into systemic circulation either by open massage via sternotomy or anterolateral thoracotomy or spontaneously after aorta clamping in the chest or in the abdomen at the epigastrium under extracorporeal resuscitation and induced hypothermia. This is the only way to prevent ischemic damage to the brain and the heart. This is accomplishable rapidly and efficiently only by a direct approach, which is a crush laparotomy if the bleeding is coming from an abdominal +/- lower limb site or rapid sternotomy/anterolateral thoracotomy if the bleeding is coming from a chest +/- upper limbs site. Without first stopping the bleeding and refilling the heart, any further exercise is doomed to failure. Direct source control via laparotomy/thoracotomy, with the concomitant or soon following venous refilling, are the two essential, initial life-saving steps.

Application of damage control surgery in patients with sacrococcygeal deep decubitus ulcers complicated by sepsis

Objective

To evaluate the clinical application of damage control surgery (DCS) in patients with sacrococcygeal deep decubitus ulcers complicated by sepsis.

Methods

We conducted a 3-year retrospective clinical study of 32 patients with deep sacrococcygeal bedsores and sepsis admitted from January 2018 to January 2021. According to the concept of DCS, the wound was temporarily closed with vacuum sealing drainage after primary debridement, and a local rhomboid flap was designed to repair the wound in the second stage. Finally, the clinical therapeutic effect was observed.

Results

Twenty-nine patients were treated with skin flap translocation and were cured clinically. Specifically, the skin flap survived in 27 of the 29 patients after the first translocation attempt (success rate of 93.1%). One patient developed incisional dehiscence, and one patient developed a hydrocele under the skin flap.

Conclusions

Application of DCS in patients with sacrococcygeal deep decubitus ulcers complicated by sepsis improves the therapeutic success rate and reduces the risks of the operation and complication rate. It has unique advantages and is worthy of clinical promotion.

Lessons learnt from the Pietermaritzburg experience with damage control laparotomy for trauma

INTRODUCTION

The modern concept of damage control surgery (DCS) for trauma was first introduced less than three decades ago. This audit aims to describe the spectrum and outcome of patients requiring DCS, to benchmark our experience against that reported from other centres and countries and to distil the pertinent teaching lessons from this experience.

METHODS

All patients over the age of 15 years undergoing a laparotomy for trauma over the period from December 2012 to July 2016 were retrieved from the trauma registry of the Pietermaritzburg Metropolitan Trauma Service, South Africa. Physiological parameters and visceral injuries were assessed. Statistical analysis was performed using STATA V.15.0.

RESULTS

A total of 562 patients underwent trauma laparotomy during the period under review. The mechanism was penetrating trauma in 81% of cases (453/562). A great proportion of trauma victims were male (503/562, 90%), with a mean age of 29.5±10.8. A total of 99 of these (18%) had a DCS procedure versus 463 (82%) non-DCS. Out of the 99 who required DCS, there were 32 mortalities (32%). The mean physiological parameters for the DCS patient demonstrated acidosis (pH 7.28±0.15) with a raised lactate (5.25 mmol/L±3.71). Our primary repair rates for enteric injuries were surprisingly high.

CONCLUSION

Just under 20% of trauma laparotomies require DCS. In this cohort of patients, the mortality rate is just under one-third. Further attention must be paid to refining the appropriate indications for DCS as the margin for error in such a cohort is very small and poor decision-making is difficult to correct. The major lesson from this analysis is that the decision to perform DCS must be made early and communicated appropriately to all those managing the patient.