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Traumatic injuries continue to be on the rise globally and with it, the role interventional radiology (IR) has also expanded in managing this patient cohort. The role of damage control surgery (DCS) has been well established in the trauma management pathway, however it is only recently that Damage Control IR (DCIR) has become increasingly utilized in managing the extremis trauma and emergency patient. Visceral artery embolizations (both temporary and permanent), temporary balloon occlusions including Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in iliac arteries and aorta respectively are amongst the treatment options now available for the trauma (and non-traumatic bleeding) patient. We review the literature for the role of DCS and utilization of IR in trauma, outcomes and the paradigm shift towards minimally invasive techniques. The focus of this paper is to highlight the importance of multi-disciplinary working and having established pathways to ensure timely treatment of trauma patients as well as careful patient selection. We show that outcomes are best when both surgical and IR are involved in patient care from the outset and that DCIR should not be defined as Non-Operative Management (NOM) as it currently is categorized as. [ABSTRACT FROM AUTHOR]

Purpose: On 22 March 2016, the burn unit (BU) of Queen Astrid Military Hospital assessed a surge in severely injured victims from terror attacks at the national airport and Maalbeek subway station according to the damage control resuscitation (DCR) and damage control surgery (DCS) principles. This study delves into its approach to identify a suitable triage scoring system and to determine if a BU can serve as buffer capacity for mass casualty incidents (MCIs). Methods: The study reviewed retrospectively the origin of explosion, demographic data, sustained injuries, performed surgery, and length of stay of all admitted patients. Trauma scores (Injury Severity Score (ISS) and New Injury Severity Score (NISS)) and triage scores (Revised Trauma Score (RTS), New Trauma Score (NTS), and Trauma Score Injury Severity Score (TRISS)), were compared to burn mortality scores (Osler updated Baux Score and Tobiasen's Abbreviated Burn Severity Index (ABSI)). Results: Of the 23 casualties admitted to the BU, the scores calculated on average 3.5 indications for a level 1 trauma center (ISS 4, NISS 6, RTS 0, T-NTS 4). Nevertheless, no deaths occurred during admission or the 1-year follow-up. Conclusion: MCIs create chaos and a high demand for care. Avoiding bottlenecks and adhering to the DCR/DCS principles are necessary to deliver the best care to the largest number of people. This study indicates that a BU can serve as buffer capacity for MCIs. Nevertheless, its integration into the medical resilience plan depends on accurate scoring, comprehensive care availability, and understanding of the DCR/DCS concept. NTS for triage seems the best fit for scoring polytrauma referrals to a BU during MCIs. [ABSTRACT FROM AUTHOR]

Background: The rupture of splenic artery pseudoaneurysm (SAP) is life-threatening disease, often caused by trauma and pancreatitis. SAPs often rupture into the abdominal cavity and rarely into the stomach. Case presentation: A 70-year-old male with no previous medical history was transported to our emergency center with transient loss of consciousness and tarry stools. After admission, the patient become hemodynamically unstable and his upper abdomen became markedly distended. Contrast-enhanced computed tomography performed on admission showed the presence of a splenic artery aneurysm (SAP) at the bottom of a gastric ulcer. Based on the clinical picture and evidence on explorative tests, we established a preliminary diagnosis of ruptured SAP bleeding into the stomach and performed emergency laparotomy. Intraoperative findings revealed the presence of a large intra-abdominal hematoma that had ruptured into the stomach. When we performed gastrotomy at the anterior wall of the stomach from the ruptured area, we found pulsatile bleeding from the exposed SAP; therefore, the SAP was ligated from inside of the stomach, with gauze packing into the ulcer. We temporarily closed the stomach wall and performed open abdomen management, as a damage control surgery (DCS) approach. On the third day of admission, total gastrectomy and splenectomy were performed, and reconstruction surgery was performed the next day. Histopathological studies of the stomach samples indicated the presence of moderately differentiated tubular adenocarcinoma. Since no malignant cells were found at the rupture site, we concluded that the gastric rupture was caused by increased internal pressure due to the intra-abdominal hematoma. Conclusions: We successfully treated a patient with intragastric rupture of the SAP that was caused by gastric cancer invasion, accompanied by gastric rupture, by performing DCS. When treating gastric bleeding, such rare causes must be considered and appropriate diagnostic and therapeutic strategies should be designed according to the cause of bleeding. [ABSTRACT FROM AUTHOR]

Purpose: The most complex injuries are usually least often encountered by trauma team members, limiting learning opportunities at work. Identifying teaching formats that enhance trauma skills can guide future curricula. This study evaluates self-assessed technical and nontechnical trauma skills and their integration into novel work situations for multidisciplinary trauma masterclass participants. Methods: This mixed methods study included participants of a multidisciplinary 3-day trauma masterclass. Ratings of trauma skills were collected through pre- and postcourse questionnaires with 1-year follow-up. Qualitative semi-structured interviews 9 months postcourse focused on the course format and self-perceived association with technical and nontechnical skills applied at work. Results: Response rates of pre- and postcourse questionnaires after 1 day, 3 months, and 1 year were respectively 72% (51/71), 85% (60/71), 34% (24/71), and 14% (10/71). Respondents were surgeons (58%), anesthesiologists (31%), and scrub nurses (11%). Self-efficacy in nontechnical (mean 3.4, SD 0.6 vs. mean 3.8, SD 0.5) and technical (mean 2.9, SD 0.6 vs. mean 3.6, SD 0.6) skills significantly increased postcourse (n = 40, p < 0.001). Qualitative interviews (n = 11) demonstrated that increased self-efficacy in trauma skills was the greatest benefit experienced at work. Innovative application of skills and enhanced reflection demonstrate adaptive expertise. Small-group case discussions and the operative porcine laboratory were considered the most educational working formats. The experienced faculty and unique focus on multidisciplinary teamwork were highly valued. Conclusion: Course participants' self-assessed work performance mostly benefited from greater self-efficacy and nontechnical skills. Future trauma curricula should consider aligning the teaching strategies accordingly. [ABSTRACT FROM AUTHOR]

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Introduction: Damage control strategies in resuscitation and (fracture) surgery have become standard of care in the treatment of severely injured patients. It is suggested that damage control improves survival and decreases the incidence of organ failure. However, these strategies can possibly increase the risk of complications such as infections. Indication for damage control procedures is guided by physiological parameters, type of injury, and the surgeon's experience. We analyzed outcomes of severely injured patients who underwent emergency surgery. Methods: Severely injured patients, admitted to a level-1 trauma center ICU from 2016 to 2020 who were in need of ventilator support and required immediate surgical intervention (≤24 h) were included. Demographics, treatment, and outcome parameters were analyzed. Results: Hundred ninety-five patients were identified with a median ISS of 33 (IQR 25–38). Ninety-seven patients underwent immediate definitive surgery (ETC group), while 98 patients were first treated according to damage control principles with abbreviated surgery (DCS group). Although ISS was similar in both groups, DCS patients were younger, suffered from more severe truncal injuries, were more frequently in shock with more severe acidosis and coagulopathy, and received more blood products. ETC patients with traumatic brain injury needed more often a craniotomy. Seventy-four percent of DCS patients received definitive surgery in the second surgical procedure. There was no difference in mortality, nor any other outcome including organ failure and infections. Conclusions: When in severely injured patients treatment is dictated by physiology into either early definitive surgery or damage control with multiple shorter procedures stretched over several days combined with aggressive resuscitation with blood products, outcome is comparable in terms of complications. [ABSTRACT FROM AUTHOR]

Introduction: Damage control surgery (DCS) is a standardized treatment concept in severe abdominal injury. Despite its evident advantages, DCS bears the risk of substantial morbidity and mortality, due to open abdomen therapy (OAT). Thus, identifying the suitable patients for that approach is of utmost importance. Furthermore, little is known about the use of DCS and the related outcome, especially in blunt abdominal trauma. Methods: Patients recorded in the TraumaRegister DGU® from 2008 to 2017, and with an Injury Severity Score (ISS) ≥ 9 and an abdominal injury with an Abbreviated Injury Scale (AIS) score ≥ 3 were included in that registry-based analysis. Patients with DCS and temporary abdominal closure (TAC) were compared with patients who were treated with a laparotomy and primary closure (non-DCS) and those who did receive non-operative management (NOM). Following descriptive analysis, a matched-pairs study was conducted to evaluate differences and outcomes between DCS and non-DCS group. Matching criteria were age, abdominal trauma severity, and hemodynamical instability at the scene. Results: The injury mechanism was predominantly blunt (87.1%). Of the 8226 patients included, 2351 received NOM, 5011 underwent laparotomy and primary abdominal closure (non-DCS), and 864 were managed with DCS. Thus, 785 patient pairs were analysed. The rate of hepatic injuries AIS > 3 differed between the groups (DCS 50.3% vs. non-DCS 18.1%). DCS patients had a higher ISS (p = 0.023), required more significant volumes of fluids, more catecholamines, and transfusions (p < 0.001). More DCS patients were in shock at the accident scene (p = 0.022). DCS patients had a higher number of severe hepatic (AIS score ≥ 3) and gastrointestinal injuries and more vascular injuries. Most severe abdominal injuries in non-DCS patients were splenic injuries (AIS, 4 and 5) (52.1% versus 37.9%, p = 0.004). Conclusion: DCS is a strategy used in unstable trauma patients, severe hepatic, gastrointestinal, multiple abdominal injuries, and mass transfusions. The expected survival rates were achieved in such extreme trauma situations. [ABSTRACT FROM AUTHOR]

To evaluate the efficacy of the damage control approach by two-step surgical procedure in not critical patients (without sepsis or septic shock) with peritonitis from limited acute mesenteric ischemia. From April 2013 to April 2020, 85 patients [49 (57.7%) women and 36 (42.3%) men, median age 69.5 (range 38–92)] were enrolled in this study and underwent emergency surgery. After resection of ischemic bowel, basing on the individual decision of the single surgeon, the patients underwent primary end-to-end anastomosis (Group 1) or damage control approach (Group 2) including primary laparotomy with resection of ischemic bowel, temporary abdominal closure and a second-look procedure at 48 h with re-evaluation of bowel vitality. Forty-seven (55.3%) patients underwent one-stage surgical treatment and 38 (44.7%) patients received a two-step procedure. In the latter group, at second exploration, 8 (21%) patients required a further intestinal resection, due to mesenteric ischemia progression. Both anastomosis dehiscence rate and need for ileostomy in Group 1 patients were significantly higher than in Group 2 (23.4% vs 5.3%: p = 0.03 and 19.1% vs 2.6%: p = 0.03; Fisher's exact test). No significative differences in mortality and morbidity rate were found between the two groups. The damage control approach by two-step surgical procedure may represent a valid innovative option in the management of not critical patients with limited acute mesenteric ischemia, achieving a better clinical outcome if compared with surgical treatment by one-step procedure. [ABSTRACT FROM AUTHOR]

Background: Intra-abdominal hemorrhage caused by blunt hepatic injury is a major cause of morbidity and mortality in patients with abdominal trauma. Some of these patients require laparotomy, and rapid decision-making and life-saving surgery are essential. Damage control (DC) surgery is useful for treating children in critical situations. We performed this technique to treat an 8-year-old boy with grade IV blunt hepatic injury and multiple organ damage. This is the first report of the use of the ABTHERA Open Abdomen Negative Pressure Therapy System (KCI, now part of 3 M Company, San Antonio, TX, USA) for DC surgery to rescue a patient without neurological sequelae. Case presentation: An 8-year-old boy was brought to the emergency department of our hospital after being run over by a motor vehicle. He had grade IV blunt hepatic injury, thyroid injury, and bilateral hemopneumothorax. Although he was hemodynamically stable, the patient's altered level of consciousness, the presence of a sign of peritoneal irritation, and suspicion of intestinal injury led us to perform exploratory laparotomy. As part of a DC strategy, we performed gauze packing to control hemorrhage from the liver and covered the abdomen with an ABTHERA Open Abdomen Negative Pressure Therapy System to improve the patient's general condition. Eighteen days after admission, the patient was diagnosed with a biliary fistula, which improved with percutaneous and external drainage. He had no neurological sequelae and was discharged 102 days after injury. Conclusion: The DC strategy was effective in children with severe blunt hepatic injury. We opted to perform DC surgery because children have less hemodynamic reserve than adults, and we believe that using this strategy before the appearance of trauma triad of death could save lives and improve outcomes. During conservative management, it is important to adopt a multistage, flexible approach to achieve a good outcome. [ABSTRACT FROM AUTHOR]

Objectives: The objectives of this study were to gather an expert opinion survey and to evaluate the suitability of summarized indications and interventions for DCO. Background: The indications to perform temporary surgery in musculoskeletal injuries may vary during the hospitalization and have not been defined. We performed a literature review and an expert opinion survey about the indications for damage control orthopaedics (DCO). Methods: Part I: A literature review was performed on the basis of the PubMed library search. Publications were screened for damage control interventions in the following anatomic regions: "Spine", "Pelvis", "Extremities" and "Soft Tissues". A standardized questionnaire was developed including a list of damage control interventions and associated indications. Part II: Development of the expert opinion survey: experienced trauma and orthopaedic surgeons participated in the consensus process. Results: Part I: A total of 646 references were obtained on the basis of the MeSH terms search. 74 manuscripts were included. Part II: Twelve experts in the field of polytrauma management met at three consensus meetings. We identified 12 interventions and 79 indications for DCO. In spinal trauma, percutaneous interventions were determined beneficial. Traction was considered harmful. For isolated injuries, a new terminology should be used: "MusculoSkeletal Temporary Surgery". Conclusion: This review demonstrates a detailed description of the management consensus for abbreviated musculoskeletal surgeries. It was consented that early fixation is crucial for all major fractures, and certain indications for DCO were dropped. Authors propose a distinct terminology to separate local (MuST surgery) versus systemic (polytrauma: DCO) scenarios. [ABSTRACT FROM AUTHOR]

Background: The damage control approach is known to reduce the mortality rate in severely injured patients and has now become a common practice. Transcatheter arterial embolization (TAE) has been shown to be useful with combining with damage control laparotomy in identifying and controlling active arterial hemorrhage. Hybrid operating room (OR) allows both damaged control surgery and TAE in the same location in minimal time. We report a case of a patient with three cardiac arrests who was saved by early intervention using damage control surgery (DCS) with interventional radiology (IVR) in the hybrid OR. Case presentation: A 46-year-old woman was injured in a collision with a tree while snowboarding. She was eventually transported to hybrid operating room in our hospital with the diagnosis of significant liver laceration and hemorrhagic shock. Damage control surgery was performed with perihepatic packing (PHP) and TAE was conducted to stop active bleeding from right hepatic artery. She experienced 3 times of cardiopulmonary arrest, which was successfully resuscitated on each occasion. Although she had total of 3 times of laparotomy but tolerated well. She was discharged on day 82 of hospitalization and showed no neurological sequelae. Conclusion: Saving the life of a patient with severe trauma requires a multidisciplinary approach with cooperation and early information sharing among trauma team members. Sharing treatment strategy with the trauma team and early intervention using DCS with IVR in the hybrid operating room could save the patient's life. [ABSTRACT FROM AUTHOR]

The liver is the largest intrabdominal organ in the body with thin capsule and is more vulnerable to injury especially in blunt abdominal trauma. It is the second most common organ to be injured, but unfortunately liver injury contributes maximum in terms of mortality in intraabdominal trauma.The initial assessment and resuscitation should go together. The recent trend of NOM (nonoperative management) in liver trauma has been possible because of better understanding of the anatomy of the liver, pathophysiology of liver trauma, imaging modalities like FAST and CECT, and development of interventional radiology like angio-embolization. DCS (damage control surgery) also plays an important part in an unstable patient with liver trauma before undertaking definitive surgery once lethal triad of acidosis, hypothermia, and coagulopathy is corrected after DCS. [ABSTRACT FROM AUTHOR]

Introduction: Damage control surgery (DCS) is the classic approach to manage severe trauma and has recently also been considered an appropriate approach to the treatment of critically ill patients with severe intra-abdominal sepsis. The purpose of the present review is to evaluate the outcomes following DCS for Hinchey II–IV complicated acute diverticulitis (CAD). Methods: A comprehensive systematic search was undertaken to identify all randomized clinical trials (RCTs) and observational studies, irrespectively of their size, publication status, and language. Adults who have undergone DCS for CAD Hinchey II, III, or IV were included in this review. DCS is compared with the immediate and definitive surgical treatment in the form of HP, colonic resection, and primary anastomosis (RPA) with or without covering stoma or laparoscopic lavage. We searched the following electronic databases: PubMed MEDLINE, Scopus, and ISI Web of Knowledge. The protocol of this systematic review and meta-analysis was published on Prospero (CRD42020144953). Results: Nine studies with 318 patients, undergoing DCS, were included. The presence of septic shock at the presentation in the emergency department was heterogeneous, and the weighted mean rate of septic shock across the studies was shown to be 35.1% [95% CI 8.4 to 78.6%]. The majority of the patients had Hinchey III (68.3%) disease. The remainder had either Hinchey IV (28.9%) or Hinchey II (2.8%). Phase I is similarly described in most of the studies as lavage, limited resection with closed blind colonic ends. In a few studies, resection and anastomosis (9.1%) or suture of the perforation site (0.9%) were performed in phase I of DCS. In those patients who underwent DCS, the most common method of temporary abdominal closure (TAC) was the negative pressure wound therapy (NPWT) (97.8%). The RPA was performed in 62.1% [95% CI 40.8 to 83.3%] and the 22.7% [95% CI 15.1 to 30.3%]: 12.8% during phase I and 87.2% during phase III. A covering ileostomy was performed in 6.9% [95% CI 1.5 to 12.2%]. In patients with RPA, the overall leak was 7.3% [95% CI 4.3 to 10.4%] and the major anastomotic leaks were 4.7% [95% CI 2.0 to 7.4%]; the rate of postoperative mortality was estimated to be 9.2% [95% CI 6.0 to 12.4%]. Conclusions: The present meta-analysis revealed an approximately 62.1% weighted rate of achieving GI continuity with the DCS approach to generalized peritonitis in Hinchey III and IV with major leaks of 4.7% and overall mortality of 9.2%. Despite the promising results, we are aware of the limitations related to the significant heterogeneity of inclusion criteria. Importantly, the low rate of reported septic shock may point toward selection bias. Further studies are needed to evaluate the clinical advantages and cost-effectiveness of the DCS approach. [ABSTRACT FROM AUTHOR]

Open abdomen or laparostomy as a method of damage control in emergency surgery especially with perforated viscus has been used mainly to prevent abdominal compartment syndrome, burst abdomen and delayed ventral hernia. The authors aimed to study the associated morbidity of open abdomen with clinical and resuscitative parameters. A historical cohort of patients with open abdomen after emergency laparotomy at Trauma Centre AIIMS, New Delhi, from January 2013 to December 2017 was included in this analysis. Patients operated elsewhere came to this hospital for further care; patients with AIS (abbreviated injury score) > 3 in other body regions and patients who died within 48 h were excluded. These patients were studied for their requirement of more than usual post-operative care in the form of requirement of resuscitative measures and other vital clinical parameters. A comparative analysis of patients with and without intra-abdominal complications (enteric fistula and intra-abdominal sepsis) was performed. Of the 113 subjects studied from historical case records, 52 had intra-abdominal sepsis and 10 had entero-cutaneous fistulae. These patients in comparison with those who did not undergo laparotomy during the same period did not require extra efforts for resuscitation, ICU care, increased hospital stay, chest infection and other clinical and biochemical morbid parameters. Immediate post-operative period in this cohort of patients with open abdomen was not associated with extra effort to resuscitate or burden on clinical work. Early definitive closure of abdomen is recommended once patients are stabilised to avoid laparostomy-related complications. [ABSTRACT FROM AUTHOR]

Background: The mortality of abdominal vena caval injuries is as high as 50–80%. Yet, there were few reports on how to repair injured inferior vena cava (IVC). This report presents a method of vena caval repair in a case of penetrating retrohepatic IVC injury, requiring hepatic resection and total vascular exclusion (TVE). Case presentation: The patient was a 20-year-old man with a stab wound in the epigastrium. An emergency laparotomy was performed in the emergency room, and a stab incision on the left liver was detected. As the Pringle's maneuver did not reduce bleeding, hepatic vein injury was suspected, and left hemihepatectomy was performed to confirm the bleeding point. After the hepatectomy, laceration was still evident deeper into the resection, and IVC injury was suspected. The bleeding was temporarily controlled by tentative hepatorrhaphy and gauze packing, and the initial damage control surgery was terminated. Definitive surgery was performed on the third postoperative day. The lacerated point was observed under TVE, and the laceration penetrated the retrohepatic IVC through its posterior wall. The slit of the posterior wall was sutured first, followed by suturing of the anterior wall of the IVC. Finally, the lacerated liver was closed with hepatorrhaphy. TVE was removed, and the massive bleeding was successfully controlled. Conclusion: In severe liver injuries involving the retrohepatic IVC, hepatic resection and TVE may be useful for ensuring an optimized surgical field for repairing the injured IVC. [ABSTRACT FROM AUTHOR]

Background: Damage control surgery (DCS) with open abdominal management (OAM) has been increasingly expanded to include critically ill non-trauma patients. However, there is limited data regarding the usefulness of this protocol for the treatment of severe perforative peritonitis (PP), especially with septic shock (SS). Here, we retrospectively evaluated the usefulness of our OAM protocol for PP with SS. Methods: We retrospectively reviewed patients with from June 2015 to September 2018. The proposed protocol was composed of the following steps: (1) rapid control of contamination; (2) temporary abdominal closure; (3) repeated washout of the abdominal cavity; and (4) delayed definitive surgery. For temporary abdominal closure, a negative pressure wound therapy device was used. The end points were the morbidity and 30-day mortality rates. Logistic backward regression was performed to identify factors associated with complications. Results: The mortality rate was 4% (1/25) and the overall morbidity rate of surviving patients was 58.3% (14/24). The mean duration of the first DCS was 67.36 ± 22.83 min. The median durations of ventilation and intensive care unit stay were 5 and 7 days, respectively. Although not significant, morbidity might be associated with age, diabetes mellitus, initial operative time, and OAM duration. Conclusions: A standardized protocol for OAM may improve the outcomes of patients with SS due to PP. This damage control approach can be applied for the treatment of severe abdominal sepsis. [ABSTRACT FROM AUTHOR]

Background: Due to a decreasing number of emergency procedures for body cavity injuries, surgical training is inadequate and current educational concepts must be reconsidered. The German Society for General and Visceral Surgery has set up a surgical training course in 2014 to overcome this shortage. In order to assess the eligibility, needs, benefits and success of such a training format, participants were asked to evaluate the program. Material and methods: All participants evaluated the course during participation and were later asked to answer an online survey regarding their age, gender, level of surgical education, surgical discipline, level of care of the hospital, emergency surgical experience and frequency of performing emergency surgery, participation in other programs, experiences after participating in the course, rating of the current training curriculum and funding of such courses. Results: Out of 142 participants 83 replied to the online survey. Over 90% reported a lasting positive influence of the course on emergency surgical skills. More than half of the responders remembered a clinical situation which they successfully managed due to the skills they gained during the course. Surgeons experienced in emergency treatment felt significantly more benefit than less experienced colleagues. A consultancy position, the level of care of the hospital, age and sex of the participants did not influence the overall benefits reported. The majority of responding surgeons were in favor of including such a training course in surgical education and stipulated public financial support. Conclusion: Course formats that mediate emergency surgery strategies and skills are established and well accepted. Training of surgeons in life-saving emergency surgery is in the public interest and is also partly the responsibility of society. [ABSTRACT FROM AUTHOR]

The management of patients with penetrating abdominal trauma has significantly changed in recent years. While exploratory laparotomy was the gold standard in Germany in all patients up to the 1970s, selective nonoperative management (SNOM) is increasingly being discussed in hemodynamically stable patients without pathological findings in computed tomography (CT) scan or extended focussed assessment with sonography for trauma (eFAST). A standard algorithm taking a balance between invasiveness, patient safety and the use of resources into account has still to be implemented in Germany. The presented algorithm includes an immediate laparotomy in hemodynamically unstable patients as damage control surgery followed by a second look procedure after 48 h. Hemodynamically stable patients should primarily undergo diagnostic laparoscopy and be treated by early total care surgery, depending on the clinical and diagnostic imaging findings. Patients without clinical symptoms or pathological findings in imaging studies should be treated according to SNOM with close clinical controls. [ABSTRACT FROM AUTHOR]

Terrorism-related incidents and shootings that involve the use of war weapons and explosives are associated with gunshot and blast injuries. Despite the perceived threat of terrorism, these incidents and injuries are rare in Germany. For this reason, healthcare providers are unlikely to have a full understanding of the special aspects of managing these types of injuries. Until a clear and complete picture of the situation is available after a terrorist or shooter incident, tactical and strategic approaches to the clinical management of the injured must be tailored to circumstances that have the potential to overwhelm resources temporarily. Hospitals providing initial care must be aware that the first patients who are taken to medical facilities will present with uncontrollable bleeding from injuries to the trunk and body cavities. To improve the outcome of these patients in extremis, the aim of the index surgery is to stop the bleeding and control the contamination. Unlike damage control surgery, which is tailored to the patient's condition, tactical abbreviated surgical care (TASC) is first and foremost adapted to the overall situation. Once the patients are stabilised and all information on the situation is available, the surgical management and reconstruction of gunshot and blast injuries can follow the principles of damage control (DC) and definitive early total care (ETC). The purpose of this article is to provide an overview of the pathophysiology of gunshot and blast injuries, wound ballistics, and the approach and procedures of successful surgical management. [ABSTRACT FROM AUTHOR]

Femoral shaft fractures mostly result from high-energy trauma and young adult males are typically affected. The standard treatment is antegrade reamed interlocking medullary nailing. Retrograde nailing and plate fixation are other treatment options. In polytraumatized patients, primary management according to the guidelines of damage control surgery includes initial fracture fixation with an external fixator before scheduled early secondary definitive fixation is performed. Particularly in complex fractures, restoration of the length and rotation can represent some challenges for the surgeon. This article provides tips and tricks for the effective management of femoral shaft fractures. [ABSTRACT FROM AUTHOR]

The idea of damage control (DC) is grounded on a sequential therapeutic strategy that supports physiological restoration over anatomic repair in critically injured patients. This concept is firstly described as damage control surgery (DCS) for war-wounded patients with abdominal exsanguinating trauma. The goal was to avoid prolonged operative times and prevent the outset of the lethal cycle of hypothermia, acidosis and coagulopathy. Damage control orthopedics (DCO) is also based on this concept and it is applied in the treatment of some polytrauma patients with pelvic and long bones fractures as to avoid the "second hit" of a lengthy definitive operation and eliminate initial morbidity and mortality. It is in favor of primary fracture stabilization utilizing provisional external fixation. When the patient is in stable condition, conversion to definitive open reduction and intramedullary nailing can be done. This stepwise approach should be considered as a part of the resuscitation process, and it follows the saying "do no further harm". [ABSTRACT FROM AUTHOR]

Non-operative management has become a norm in patients with liver trauma and operative management is guided by hemodynamic status. Introduction of haemodynamic status. Introduction of contrast enhanced computed tomography (CECT) abdomen has made NOM possible by helping in exclusion of other injuries and identification of vascular injuries. Haemodynamic instability is now considered as an only absolute indication for operative intervention in liver injuries. However, liver trauma is associated with a large number of complications in the form of perihepatic abscess, hepatic necrosis, bile leak, etc. Patient's undergoing operative intervention for liver trauma are more at risk for these complications. As such regular dynamic assessment is required for early identification and management of these complications. We present a case of a complex liver injury in a 27-year-old male who underwent operative intervention for liver trauma and had a varied number of liver trauma associated complications, with enterohepatic fistula as one of the rarest associated complications. [ABSTRACT FROM AUTHOR]

Copyright of Der Unfallchirurg is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Purpose: Damage control strategy (DCS) is a two-staged procedure for the treatment of perforated diverticular disease complicated by generalized peritonitis. The aim of this retrospective multicenter cohort study was to evaluate the prognostic impact of an ongoing peritonitis at the time of second surgery.Methods: Consecutive patients who underwent DCS for perforated diverticular disease of the sigmoid colon with generalized peritonitis at four surgical centers were included. Damage control strategy is a two-stage emergency procedure: limited resection of the diseased colonic segment, closure of oral and aboral colon, and application of a negative pressure assisted abdominal closure system at the initial surgery followed by second laparotomy 48 h later. Therein, decision for definite reconstruction (anastomosis or Hartmann’s procedure (HP)) is made. An ongoing peritonitis at second surgery was defined as presence of visible fibrinous, purulent, or fecal peritoneal fluid. Microbiologic findings from peritoneal smear at first surgery were collected and analyzed.Results: Between 5/2011 and 7/2017, 74 patients underwent a DCS for perforated diverticular disease complicated by generalized peritonitis (female: 40, male: 34). At second surgery, 55% presented with ongoing peritonitis (OP). Patients with OP had higher rate of organ failure (32 vs. 9%, p = 0.024), higher Mannheim Peritonitis Index (25.2 vs. 18.9; p = 0.001), and increased operation time (105 vs. 84 min., p = 0.008) at first surgery. An anastomosis was constructed in all patients with no OP (nOP) at second surgery as opposed to 71% in the OP group (p < 0.001). Complication rate (44 vs. 24%, p = 0.092), mortality (12 vs. 0%, p = 0.061), overall number of surgeries (3.4 vs. 2.4, p = 0.017), enterostomy rate (76 vs. 36%, p = 0.001), and length of hospital stay (25 vs. 18.8 days, p = 0.03) were all increased in OP group. OP at second surgery occurred significantly more often in patients with Enterococcus infection (81 vs. 44%, p = 0.005) and with fungal infection (100 vs. 49%, p = 0.007). In a multivariate analysis, Enterococcus infection was associated with increased morbidity (67 vs. 21%, p < 0.001), enterostomy rate (81 vs. 48%, p = 0.017), and anastomotic leakage (29 vs. 6%, p = 0.042), whereas fungal peritonitis was associated with an increased mortality (43 vs. 4%, p = 0.014).Conclusion: Ongoing peritonitis after DCS is a predictor of a worse outcome in patients with perforated diverticulitis. Enterococcal and fungal infections have a negative impact on occurrence of OP and overall outcome. [ABSTRACT FROM AUTHOR]

The treatment of patients in the context of mass casualty incidents (MCI) represents a great challenge for the participating rescue workers and clinics. Due to the increase in terrorist activities it is necessary to become familiar with this new kind of threat to civilization with respect to the medical treatment of victims of terrorist attacks. There are substantial differences between a 'normal' MCI and a terrorist MCI with respect to injury patterns (blunt trauma vs. penetrating/perforating trauma), the type and form of the incident (MCI=static situation vs. terrorist attack MCI= dynamic situation) and the different security positions (rescue services vs. police services). This article is concerned with question of which changes in the surgical treatment of patients are made necessary by these new challenges. In this case it is necessary that physicians are familiar with the different injury patterns, whereby priority must be given to gunshot and explosion (blast) injuries. Furthermore, altered strategic and tactical approaches (damage control surgery vs. tactical abbreviated surgical care) are necessary to ensure survival for as many victims of terrorist attacks as possible and also to achieve the best possible functional results. It is only possible to successfully counter these new challenges by changing the mindset in the treatment of terrorist MCI compared to MCI incidents. An essential component of this mindset is the acquisition of a maximum of flexibility. This article would like to make a contribution to this problem. [ABSTRACT FROM AUTHOR]

While intestinal injury is relatively rare in blunt abdominal trauma, it is common in penetrating abdominal trauma. Intestinal injury cannot be detected effectively by computed tomography (CT); therefore penetrating abdominal injury or abdominal signs in blunt trauma require liberal indications for explorative laparotomy. In mass casualty situations patients with hemodynamic instability and abdominal signs should be prioritized for surgery. Besides intra-abdominal hemorrhage the major issue is septic complications due to intestinal perforation. The current surgical strategy should reflect the number of injured patients and the individual pattern of injuries. Damage control surgery is not an effective strategy to improve survival rates in severely injured patients or in mass casualty situations. Damage control surgery focuses on lifesaving procedures especially bleeding control and control of contamination. This includes an open abdomen strategy with later definitive repair and abdominal wall closure [ABSTRACT FROM AUTHOR]

Introduction: The damage control orthopedics (DCO) concept is a sequential surgical management strategy indicated when ideal primary treatment is not possible or suitable. DCO principles are routinely applied to hand traumas in wartime practice, but could also be useful in a civilian setting when immediate specialized management cannot be carried out.Methods: The authors report three typical observations of soldiers treated for a complex hand trauma on the field by orthopedic surgeons from the French Military Health Service (FMHS). Application of the hand DCO concept is analyzed and discussed considering the literature and the FMHS experience.Results: With regards to treating the hand, DCO necessitates a meticulous debridement with precise wound assessment, the frequent use of a primary definitive internal fixation by K-wires, and the possibility of a temporary coverage. These simple and fast procedures help avoid infection and prepare the hand for secondary repair.Conclusion: Hand DCO can be applied by any surgeon in various situations: in association with polytrauma, complex injuries requiring multiple reconstructions, or delayed transfer to a specialized center. [ABSTRACT FROM AUTHOR]

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Purpose: This study investigated the advantages of performing urgent resuscitative surgery (URS) in the emergency department (ED); namely, our URS policy, to avoid a delay in hemorrhage control for patients with severe torso trauma and unstable vital signs. Methods: We divided 264 eligible cases into a URS group ( n = 97) and a non-URS group ( n = 167) to compare, retrospectively, the observed survival rate with the predicted survival using the Trauma and Injury Severity Score (TRISS). Results: While the revised trauma score and the injury severity score were significantly lower in the URS group than in the non-URS group, the observed survival rate was significantly higher than the predicted rate in the URS (48.5 vs. 40.2%; p = 0.038). URS group patients with a systolic blood pressure (SBP) <90 mmHg and a Glasgow coma scale (GCS) score of ≥9 had significantly higher observed survival rates than predicted survival rates (0.433 vs. 0.309, p = 0.008), (0.795 vs. 0.681, p = 0.004). The implementation of damage control surgery (DCS) was found to be a significant predictor of survival (OR 5.23, 95% CI 0.113-0.526, p < 0.010). Conclusion: The best indications for the URS policy are an SBP <90 mmHg, a GCS ≥9 on ED arrival, and/or the need for DCS. By implementing our URS policy, satisfactory survival of patients requiring immediate hemostatic surgery was achieved. [ABSTRACT FROM AUTHOR]

Background: Time is a crucial factor for the successful early management of the multi-trauma patient. Hybrid operating theaters, which support the integration of surgical treatment and interventional radiology, provide opportunities to reduce the time-to-surgery for life threatening conditions. Case presentation: We describe the early successful treatment of a 54-year-old male who sustained multiple injuries when he was hit by a 1000 kg bale of wheat that fell from a height. He was admitted with hemorrhagic shock due to intra-abdominal bleeding, an unstable fracture of the pelvis, and blunt aortic injury, which was considered to be at high risk of rupture. External fixation was applied to the pelvis in the resuscitation bay, and the patient was transferred to a hybrid operating theater for treatment of both the intra-abdominal hemorrhage and blunt aortic injury. Damage control laparotomy and thoracic endovascular aortic repair were performed uneventfully. Conclusions: Hybrid treatment, which combines emergency surgery and intraoperative interventional radiology, provides a prompt and appropriate management approach for the treatment of patients with severe multiple trauma and may improve patient outcomes. [ABSTRACT FROM AUTHOR]

Background: This study evaluated factors influencing mortality in a large cohort of patients who sustained pancreatic injuries and underwent DCS. Methods: A prospective database of consecutive patients with pancreatic injuries treated at a Level 1 academic trauma centre was reviewed to identify those who underwent DCS between 1995 and 2014. Results: Seventy-nine (71 men, median age: 26 years, range 16-73 years, gunshot wounds = 62, blunt = 14, stab = 3) patients with pancreatic injuries (35 proximal, 44 distal) had DCS. Fifty-nine (74.7 %) patients had AAST grade 3, 4 or 5 pancreatic injuries. The 79 patients had a total of 327 associated injuries (mean: 3 per patient, range 0-6) and underwent a total of 187 (range 1-7) operations. Vascular injuries (60/327, 18.3 %) occurred in 41 patients. Twenty-seven (34.2 %) patients died without having a second operation. The remaining 52 patients had two or more laparotomies (range 2-7). Overall 28 (35 %) patients underwent a pancreatic resection either during DCS ( n = 18) or subsequently as a secondary procedure ( n = 10) including a Whipple ( n = 6) when stable. Overall 43 (54.4 %) patients died. Mortality was related to associated vascular injuries overall ( p < 0.01), major visceral venous injuries ( p < 0.01) and combined vascular and total number of associated organs injured ( p < 0.04). Conclusions: Despite the magnitude of their combined injuries and the degree of physiological insult, DCS salvaged 45 % of critically injured patients who later underwent definitive pancreatic surgery. Mortality correlated with associated vascular injuries overall, major visceral venous injuries and the combination of vascular plus the total number of associated organs injured. [ABSTRACT FROM AUTHOR]

Trauma surgeons must recognize life-threatening injuries, understand their mechanisms and pathophysiology, and be able to perform lifesaving procedures in order to preserve a patient's life. In the past, training in general surgery and additionally in trauma surgery has provided trauma surgeons with primary trauma competence and experience in secondary definitive reconstructive procedures of the prevailing trauma pattern. The new route to special traumatology via orthopaedic or trauma surgery specialist impedes reaching this wide primary trauma competence. In reality, today's orthopaedic trauma specialist does not meet the expectations needed for primary general trauma care, but will dedicate him/herself to focusing on a specific injury pattern or body region for secondary elective treatment. Therefore, in the future, we will need surgeons more like the American acute care surgeon or the British model of the emergency general surgeon, who deal with acute surgical emergencies and severe trauma conditions, and - most importantly - remain involved in elective surgical procedures in order to prevent getting out of sufficient practice. [ABSTRACT FROM AUTHOR]

Background: Severe blunt hepatic injury is a major cause of morbidity and mortality in pediatric patients. Damage control (DC) surgery has been reported to be useful in severely compromised children with hepatic injury. We applied such a technique in the treatment of a case of hemodynamically unstable grade IV blunt hepatic injury in an eight-year-old girl. This case is the first to use multimodal approaches including perihepatic packing, temporary closure of the abdominal wall with a plastic sheet, transarterial embolization (TAE), and planned delayed anatomical hepatic resection in a child. Case presentation: An eight-year-old girl was run over by a motor vehicle and transferred to the emergency department of the local hospital. Her diagnoses were severe blunt hepatic injury (grade IV) with left femoral trochanteric fracture. No other organ injuries were observed. Because her hemodynamic state was stable under aggressive fluid resuscitation, she was transferred to our hospital for surgical management. On arrival at our institution about 4 h after the injury, her hemodynamic condition became unstable. Abdominal compartment syndrome also became apparent. Because her condition had deteriorated and the lethal triad of low BT, coagulopathy, and acidosis was observed, a DC treatment strategy was selected. First, emergent laparotomy was performed for gauze-packing hemostasis to control intractable bleeding from the liver bed, and the abdomen was temporarily closed with a plastic sheet with continuous negative pressure aspiration. Transarterial embolization of the posterior branch of the right hepatic artery was then carried out immediately after the operation. The lacerated right lobe of the liver was safely resected in a stable hemodynamic condition 2 days after the initial operation. Bleeding from the liver bed ceased without further need of hemostasis. She was transferred to the local hospital without any surgical complications on day 42 after admission. She had returned to her normal life by 3 months after the injury. Conclusion: The DC strategy was found to be effective even in a pediatric patient with hemodynamically unstable severe blunt hepatic injury. The presence of the deadly triad (hypothermia, coagulopathy, and acidosis) and abdominal compartment syndrome was an indication for DC surgery. [ABSTRACT FROM AUTHOR]

Background: In 2009, during the war in Afghanistan, the increasing number of head injuries led to the deployment of a military neurosurgeon at the Kabul International Airport (KaIA) medical treatment facility, in March 2010. The main goal of this study was to depict the neurosurgical activity in this centre and to analyse its different aspects. Method: A retrospective study of all the neurosurgical patients treated in KaIA from March 2010 to June 2013. Results: Three hundred and seventy-three interventions performed by the neurosurgeon deployed were reported for 373 surgeries, in 335 patients, representing 10.6 % of the overall surgical activity of the centre. Among the 69 interventions performed on soldiers, 57 surgeries were undertaken in emergency (82.6 %), while 12 were elective procedures (17.4 %). On the other hand, 289 surgeries were performed in civilian Afghans, with 126 emergency procedures in (43.6 %), against 163 elective interventions (56.4 %). Among the 44.5 % ( n = 149) of the traumatic casualties, cerebral lesions represented 28.7 % ( n = 96) and spinal lesions 12.4 % ( n = 42). Ninety patients had multiple injuries. Additionally, patients without trauma accounted for 55.5 % ( n = 186) of the overall population. Thus, 49 % ( n = 164) were operated on for non-traumatic lesion of the spine. These were mostly civilian Afghans treated under medical aid to the population (90.2 %, n = 148/164). Conclusions: The military neurosurgeon had two roles in KaIA: both to support the armed forces and to manage medical aid to the civilian population. This study gives food for thought on the neurosurgical needs in modern warfare, and on the skills required for the military neurosurgeon. [ABSTRACT FROM AUTHOR]

Background: The best surgical strategy for the management of perforated diverticulitis with generalized peritonitis of the sigmoid colon is not clearly defined. The aim of this retrospective cohort study was to evaluate the value of a damage control strategy. Methods: All patients who underwent emergency laparotomy for perforated diverticular disease of the sigmoid colon with generalized peritonitis between 2010 and 2015 were included. The damage control strategy (study group), included a two- stage procedure: limited resection of the diseased colonic segment, closure of proximal colon and distal stump, and application of an abdominal vacuum at the initial surgery followed by second-look laparotomy 24-48 h later At this point a choice was made between anastomosis and Hartmann's procedure. The control group consisted of patients receiving definitive reconstruction (anastomosis or Hartmann's procedure) at the initial operation. Results: Thirty-seven patients were included in the study. Damage control strategy was applied in 19 patients and the control group consisted of 18 patients. Both groups were comparable in terms of demographics, severity of peritonitis, and comorbidities. The overall postoperative mortality was 11 % ( n = 4). There were no statistically significant differences between both groups regarding postoperative morbidity and mortality; however, a significantly higher proportion of patients in the control group had a stoma after the initial hospital stay (83 vs. 47 %, p = 0.038). This difference was still significant after adjustment for sex, age, Mannheim Peritonitis Index, American Society of Anesthesiologists class and presence of septic shock at presentation. At the end of the follow-up period, 15 of 17 survivors in the study group and 13 of 16 survivors in the control group had their intestinal continuity restored ( p = 0.66). Conclusions: Damage control strategy in patients with generalized peritonitis due to perforated diverticulitis leads to a significantly reduced stoma rate after the initial hospital stay without an increased risk of postoperative morbidity. [ABSTRACT FROM AUTHOR]

Background: Damage control resuscitation describes an approach to the early care of very seriously injured patients. The aim is to keep the patient alive whilst avoiding interventions and situations that risk worsening their situation by driving the lethal triad of hypothermia, coagulopathy and acidosis or excessively stimulating the immune-inflammatory system. It is critical that the concepts and practicalities of this approach are understood by all those involved in the early management of trauma patients. This review aims to summarise this and discusses current knowledge on the subject. Interventions: Damage control resuscitation forms part of an overall approach to patient care rather than a specific intervention and has evolved from damage control surgery. It is characterised by early blood product administration, haemorrhage arrest and restoration of blood volume aiming to rapidly restore physiologic stability. The infusion of large volumes of crystalloid is no longer appropriate, instead the aim is to replace lost blood and avoid dilution and coagulopathy. In specific situations, permissive hypotension may also be of benefit, particularly in patients with severe haemorrhage from an arterial source. As rapid arrest of haemorrhage is so important, team-based protocols that deliver patients rapidly but safely, via CT scan where appropriate, to operating theatres or interventional radiology suites form a critical part of this process. Conclusions: Given that interventions are so time dependent in the severely injured, it is likely that by further improving trauma systems and protocols, improvements in outcome can still be made. Further research work in this area will allow us to target these approaches more accurately to those patients who can benefit most. [ABSTRACT FROM AUTHOR]

Left brachiocephalic vein injury has not yet been reported during reconstruction after esophagectomy. A 58-year-old male patient was diagnosed with cervical esophageal squamous cell carcinoma and subsequently underwent subtotal esophagectomy followed by neo-adjuvant chemotherapy. The left brachiocephalic vein was accidentally injured when making a retrosternal space. The brachiocephalic vein was ligated followed by rapid sternotomy, and cervical esophagostomy without tumor resection and jejunostomy were performed for damage control. Complete resection of the cervical esophageal tumor and free jejunal transplantation for reconstruction were performed 55 days after the initial surgery. The patient is now well and has survived for more than 34 months after the reconstruction. Surgeons should consider left brachiocephalic vein injury when making a retrosternal space. Damage control surgery and preparation for a second surgery may be important in cases of accidental major vascular injury during esophagectomy. [ABSTRACT FROM AUTHOR]

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Background: Our experience in trauma center management increased over time and improved with development of better logistics, optimization of structural and technical resources. In addition recent Government policy in safety regulations for road traffic accident (RTA) prevention, such compulsory helmet use (2000) and seatbelt restraint (2003) were issued with aim of decreasing mortality rate for trauma. Introduction: The evaluation of their influence on mortality during the last 15 years can lead to further improvements. Methods: In our level I trauma center, 60,247 trauma admissions have been recorded between 1996 and 2010, with 2183 deaths (overall mortality 3.6 %). A total of 2,935 trauma patients with ISS >16 have been admitted to Trauma ICU and recorded in a prospectively collected database (1996-2010). Blunt trauma occurred in 97.1 % of the cases, whilst only 2.5 % were penetrating. A retrospective review of the outcomes was carried out, including mortality, cause of death, morbidity and length of stay (LOS) in the intensive care unit (ICU), with stratification of the outcome changes through the years. Age, sex, mechanism, glasgow coma scale (GCS), systolic blood pressure (SBP), respiratory rate (RR), revised trauma score (RTS), injury severity score (ISS), pH, base excess (BE), as well as therapeutic interventions (i.e., angioembolization and number of blood units transfused in the first 24 h), were included in univariate and multivariate analyses by logistic regression of mortality predictive value. Results: Overall mortality through the whole period was 17.2 %, and major respiratory morbidity in the ICU was 23.3 %. A significant increase of trauma admissions has been observed (before and after 2001, p < 0.01). Mean GCS (10.2) increased during the period (test trend p < 0.05). Mean age, ISS (24.83) and mechanism did not change significantly, whereas mortality rate decreased showing two marked drops, from 25.8 % in 1996, to 18.3 % in 2000 and again down to 10.3 % in 2004 (test trend p < 0.01). Traumatic brain injury (TBI) accounted for 58.4 % of the causes of death; hemorrhagic shock was the death cause in 28.4 % and multiple organ failure (MOF)/sepsis in 13.2 % of the patients. However, the distribution of causes of death changed during the period showing a reduction of TBI-related and increase of MOF/sepsis (CTR test trend p < 0.05). Significant predictors of mortality in the whole group were year of admission ( p < 0.05), age, hemorrhagic shock and SBP at admission, ISS and GCS, pH and BE (all p < 0.01). In the subgroup of patients that underwent emergency surgery, the same factors confirmed their prognostic value and remained significant as well as the adjunctive parameter of total amount of blood units transfused ( p < 0.05). Surgical time (mean 71 min) showed a significant trend towards reduction but did not show significant association with mortality ( p = 0.06). Conclusion: Mortality of severe trauma decreased significantly during the last 15 years as well as mean GCS improved whereas mean ISS remained stable. The new safety regulations positively influenced incidence and severity of TBI and seemed to improve the outcomes. ISS seems to be a better predictor of outcome than RTS. [ABSTRACT FROM AUTHOR]

Background: The liver is the most frequently injured solid intra-abdominal organ. The major cause of early death following severe liver trauma is exsanguination. Although perihepatic packing improves survival in severe liver trauma, this leaves parenchymal damage untreated, often resulting in post-traumatic biliary leakage and a subsequent rise in morbidity. The aim of this study was to analyze the incidence and treatment of biliary leakage following the operative management of liver trauma. Methods: Patients presenting between 2000 and 2009 to Erasmus University Medical Centre with traumatic liver injury were identified. Data from 125 patients were collected and analyzed. Sixty-eight (54 %) patients required operation. All consecutive patients with post-operative biliary complications were analyzed. Post-operative biliary complications were defined as biloma, biliary fistula, and bilhemia. Results: Ten (15 %) patients were diagnosed with post-operative biliary leakage following liver injury. Three patients with a biloma were treated with percutaneous drainage, without further intervention. Seven patients with significant biliary leakage were managed by endoscopic stenting of the common bile duct to decompress the internal biliary pressure. One patient had a relaparotomy and right hemihepatectomy to control biliary leakage and injury of the right hepatic duct. Conclusion: Biliary complications continue to occur frequently following damage control surgery for liver trauma. The majority of biliary complications can be managed without an operation. Endoscopic retrograde cholangiopancreatography (ERCP) and internal stenting represent a safe strategy to manage post-operative biliary leakage and bilhemia in patients following liver trauma. Minor biliary leakage should be managed by percutaneous drainage alone. [ABSTRACT FROM AUTHOR]

Massive bleeding with coagulopathy and hemorrhagic shock poses a potential threat to life in numerous clinical settings. Optimal treatment including the prevention of exsanguination necessitates a standardized and interdisciplinary approach. Several studies have shown the importance of massive transfusion protocols and standardized coagulation algorithms to improve survival of severely bleeding patients and to avoid secondary complications. Thus, the Helsinki declaration for patient safety in anesthesiology demands the implementation of clinical practice guidelines for the treatment of patients requiring massive transfusion. This paper introduces a standardized algorithm for the treatment of patients with massive bleeding which was developed in consensus with the German Society of Anaesthesiology and Intensive Care Medicine (DGAI). [ABSTRACT FROM AUTHOR]

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The treatment of severely injured trauma patients (polytrauma) is one of the outstanding challenges in medical care. Early in the initial course the patient’s diagnostics have to be scrupulously reevaluated by an interdisciplinary team (tertiary trauma survey) to reduce deleterious sequelae of missed injuries after the initial assessment. Severely injured patients stay in intensive care for an average of 11 days. During this time the patient’s therapy has to ensure a high quality evidence-based intensive care treatment and simultaneously has to be tailored to the current individual injuries. Because of the fact that the damage control strategy is gaining increasing acceptance, the intensive care unit plays a pivotal role in the critical time between emergency and elective surgery. Therefore a close cooperation between physicians of the intensive care unit and all surgical disciplines involved is essential to reach the aim of therapeutic efforts. After survival of emergency treatment patients with severe trauma should be reintegrated into social and occupational life as soon as possible. [ABSTRACT FROM AUTHOR]

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Severe injury leads to a severe deterioration of the patients’ immune response. The changes of the immune response after severe injury include a broad range of immune functions and may result in a status of immunosuppression, which could favor infectious complications. Therefore, immunostimulating therapies have been introduced in the therapy for severely injured patients in clinical and experimental settings. The article summarizes actual immunomodulating approaches in the treatment of trauma patients and therapeutic strategies avoiding additional immune deteriorations. Examples for an immunostimulating approach in trauma patients are interferonγ and the granulocyte macrophage-colony-stimulating factor (GM-CSF), which are summarized in this review in detail. However, the effect of such an interference in the patients’ immune response with all its different cellular targets is not yet clearly understood, and most studies focus on the reaction of circulating monocytes. In addition, further immunomodulating strategies, including nutritional support, are addressed. However, clinically established therapeutic immunomodulating strategies in trauma care so far do not exist. The impact of the accidental and also an additional surgical trauma on the immune response has been clearly demonstrated. Therefore, the idea of a “damage control orthopedic surgery” (DCOS) is not only necessary to prevent further deterioration of the homeostasis of, e.g., the coagulating system, but is also desirable in terms of minimizing the burden on the immune system. In addition, also the timing of secondary surgical treatment in trauma patient care should include an evaluation of the immune response, although the most reliable markers still need to be identified. Immunomodulating therapies in trauma patients exist on an experimental level with inconsistent results. The general management of trauma patients includes strategies that have been developed also on the basis of immunological considerations. [ABSTRACT FROM AUTHOR]

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The concept of “damage control” is established in the management of severely injured patients. This strategy saves life by deferring repair of anatomic lesions and focusing on restoring the physiology. The “lethal triad” hypothermia, coagulopathy, and acidosis are physiological criteria in the selection of injured patients for ”damage control”. Other criteria, such as scoring of injury severity or the time required to accomplish definitive repair, are also useful in determining the need for ”damage control”. The staged sequential procedures of ”damage control” include, after the selection of patients (stage 1), “damage control surgery” or “damage control orthopedics” (stage 2), resuscitation in the intensive care unit (stage 3), “second–look” operations or scheduled definitive surgery (stage 4), and the secondary reconstructive surgery (stage 5). The concept of ”damage control” was carried out in a third of 622 severely injured patients in our division. Although level I evidence is lacking, the incidence of posttraumatic complications and the mortality rate were reduced. However, better understanding of the significance and kinetics of physiological parameters including inflammatory mediators could help to optimize the “damage control” concept concerning the selection of patients and the time points of staged sequential surgery. [ABSTRACT FROM AUTHOR]