CHAPTER 59 EXSANGUINATION: RELIABLE MODELS TO INDICATE DAMAGE CONTROL
Exsanguination has been defined as an extreme form of hemorrhage with ongoing bleeding that, if not surgically controlled, will lead to death. Therefore, the speed by which the exsanguinating trauma patient moves from the prehospital, emergency department, operating room, and intensive care unit is important to survival. Certain conditions and complexes of injuries require damage control to prevent exsanguination. This chapter will describe validated indicators that can be used both preoperatively and intraoperatively to improve outcomes. This chapter will also outline current guidelines for the institution of damage control in trauma patients. Emphasis is placed on the current indications for damage control as defined by key studies. Awareness of these guidelines can improve outcomes after major intra-abdominal injuries and hemorrhage and also assist in the management of one of the well-known sequelae of damage control, the post-traumatic open abdomen.
HISTORY
In 1983, Stone was first to describe the “bailout” approach of staged surgical procedures for severely injured patients. This approach emerged after his observation that early death following trauma was associated with severe metabolic and physiologic derangements following severe exsanguinating injuries. Following massive transfusion exceeding two blood volumes in trauma and emergency surgery, severe physiologic derangement ensued and mortality was found to be greater than 60%. Profound shock along with major blood loss initiates the cycle of hypothermia, acidosis, and coagulopathy. It was at this time that hypothermia, acidosis, and coagulopathy were described as the “trauma triangle of death” or the “bloody vicious cycle.” A fourth component, dysrhythmia, which usually heralded the patient’s death, was later added by Asensio. Coagulopathy, acidosis, and hypothermia make the prolonged and definitive operative management of trauma patients dangerous. This approach, now called “damage control,” describes it as multiphasic, where reoperation occurs after correcting physiologic abnormalities.