Damage control in the critically ill and injured patient

Consideration of the following should be made preoperatively and intraoperatively with a trauma patient: shock, acidosis, and hypothermia. Shock, acidosis and hypothermia have been shown to produce a potentially irreversible coagulopathic state. These three states combined are the primary indicators of a patient who may require a damage control celiotomy. The priorities of damage control celiotomy are to identify injuries, control hemorrhage, and to control contamination. The survival of these patients also requires communication between the various disciplines involved in their care. Communication is vital in the initial emergency room resuscitation, the operating room, and with the intensive care unit staff. These areas will need to be prepared with the appropriate staffing, equipment, and training prior to the patient's arrival. Techniques for temporary closure of the abdomen and timing of reoperation are reviewed. A concerted effort to resuscitate, rewarm, and control coagulopathy must be made prior to reoperation unless uncontrolled bleeding continues, usually more than 2 units per hour. These patients may encounter multiple early and late complications, related primarily to an inability to correct physiologic deficits, increased intraabdominal pressures, sepsis, and fistula formation.