RT = Respiratory Therapist, POCT = Point of Care Testing, VS = Vital Signs, EKG = Electrocardiogram, The majority of trauma patients who are hypotensive are in hemorrhagic shock. As discussed in Chap. Prehosp Emerg Care. Compartment syndrome may develop in the abdomen even with a temporary dressing in place. Coagulopathy observed in trauma patients was thought to be a resuscitation-associated phenomenon. J Trauma. Damage control surgery aims to stop haemorrhage, restore blood flow and control wound contamination. 7. J Trauma. If there is a possibility the patient may be proceeding to the operating room, notifying the operating room team at the earliest opportunity is ideal. Twenty years ago, damage control surgery (DCS) was implemented to challenge the coagulopathy of trauma. 4. 150 years of treating severe traumatic brain injury: a systematic review of progress in mortality. Report can be called about 20–30 min prior to leaving the operating room which allows the ICU staff time to set up suctioning, warming, and massive transfusion equipment, gather pumps, tubing and supplies, and prepare for the patient as well as notify respiratory therapy to bring a ventilator to the ICU room. 2011;71:1869–72. Stein SC, Georgoff P, Meghan S, Mizra K, Sonnad SS. Military, civilian, and rural application of the damage control philosophy. Morgan K, Mansker D, Adams DB. The term ‘damage control surgery’ was coined by Rotondo and Schwab 3; they outlined the three stage approach to … Prehospital airway and ventilation management: a trauma score and injury severity score-based analysis. be prevented using damage control principles rather than attempting to treat it once it has occurred. 1. A comparative analysis of pre-hospital, clinical, and CT variables. The principles of damage control surgery were first described by Stone et al in 1983 in an attempt to reduce mortality in exsanguinating patients with coagulapathy. Despite this reality, indications for initiating DCS remain debated. 2010;69:294–301. Jabre P, Combes X, Lapostolle F, Dhaouadi M, Ricard-Hibon A, Vivien B, et al. Introduction Damage control surgery (DCS ) has been the standard of care for the last 20 years in multiple trauma patients(all cutting disciplines) Necessitated by excessive haemorrhage and high mortality from total care Damage Control … Tactical surgical intervention with temporary shunting of peripheral vascular trauma sustained during operation Iraqi freedom: one unit’s experience. Once the patient is resuscitated as defined by meeting end-organ and hemodynamic endpoints, the patient is returned to the operating room for definitive repair. Definitive repair entails restoring bowel continuity, tissue debridement, and vascular grafts and anastomoses. Perkins, J. Beekley A. This concept was extended to thoracic injuries, where relatively simple maneuvers can shorten operative time of in extremis patients. 1995;39:757–60. Chicago, IL: American Burn Association; 2010. Any extremity may be prepped, draped, and included in the operative field. If at any point the patient becomes hemodynamically unstable or physiologically deranged as in Part 1, begins re-bleeding, or demonstrates they are unable to undergo a lengthy operation, the temporary dressing may be reapplied and the patient returned to the ICU for further resuscitation. damage control Wide prepping and draping allow the surgeon access to the chest and the groin to complete all necessary procedures. Herndon DN. Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), on Damage Control: From Principles to Practice, Putting It All Together: Quality Control in Trauma Team Training, Crisis Resource Management Training in Trauma. Rasmussen TE, Clouse WD, Jenkins DH, Peck MA, Eliason JL, Smith DL. There are two goals in damage control Part 1: control of bleeding and contamination. Kragh Jr JF, Walters TJ, Baer DG, Fox CJ, Wade CE, Salinas J, et al. Kragh Jr JF, Baer DG, Walters TJ. N C Med J. Brown CV, Rhee P, Chan L, Evans K, Demetriades D, Velmahos GC. The patient should ideally spend as little time as possible— certainly no more than 20 min—in the emergency department resuscitation/trauma area including procedures and adjuncts (Fig. J Trauma. Ren Fail. Since endovascular technology has further evolved, the use of resuscitative endovascular balloon occlusion of the aorta (REBOA) in trauma is being revisited [. An airway must be established if a patient cannot protect his own. The role of secondary brain injury in determining outcome from severe head trauma. This is the ideal situation for damage control. J Trauma. Zeiler FA, Teitelbaum J, West M, Gillman LM. Damage Control Principles for Pancreatic Surgery. Examiner should be on patient’s left side to facilitate Emergency Department (ED) thoracotomy and other surgical procedures if necessary. If pressures remain high, the dressing may need to be modified, loosened, or reapplied. Upon arrival to the room, the surgeon may give the team a brief history, interventions undertaken thus far, lines and tubes in place or needed, and the overall plan for the operation. This is a preview of subscription content, log in to check access. DEFINITION • Damage control surgery is defined as the rapid initial control of hemorrhage and contamination with packing and temporary closure, followed by resuscitation in the ICU, and subsequent re-exploration and definitive repair once normal physiology has been restored. Damage control with the blast-injured patients is done in large part by controlling hemorrhage. Finger occlusion of a pedicle and the Pringle maneuver for the liver or twisting the lung at its hilum are fast techniques to control significant bleeding. DCR aims to restore homeostasis and prevent or mitigate tissue hypoxia and coagulopathy. Rotondo MF, Schwab CW, McGonigal MD, Phillips 3rd GR, Fruchterman TM, Kauder DR, et al. 2007;153:310–3. Finally, the massive transfusion protocol should be implemented as soon as deemed necessary to ensure products are available as soon as possible whether it be in the ICU or operating room. Damage control surgery involves limited surgical interventions to control haemorrhage and minimize contamination until the patient has sufficient physiological reserve to undergo definitive interventions. The lethal triad of hypothermia, coagulopathy, and acidosis appears as the patient reaches physiologic exhaustion, so waiting for the triad to develop and then undertaking damage control defeats the purpose of damage control. Chapter 18 DAMAGE CONTROL SURGERY AND HYPOTHERMIA, ACIDOSIS, AND COAGULOPATHY 319 18.1 Resuscitative surgery and damage control surgery 321 18.2 Hypothermia, acidosis, and coagulopathy 322 ACRONYMS 329 SELECTED BIBLIOGRAPHY 333. Phelan HA(1), Patterson SG, Hassan MO, Gonzalez RP, Rodning CB. dAmAge control surgery In trauma, DCS refers to performing an initial lapa - rotomy in the hemodynamically unstable patient with the goal of quickly temporizing life-threatening injuries. The principles of damage control surgery in trauma care include abbreviated surgery to control blood loss and contamination in the abdomen, simultaneous resuscitation of physiology, and definitive surgical management at a later stage after restoration of … Damage control surgery for non-traumatic abdominal emergencies. Frequent, effective communication is imperative between the prehospital and emergency department teams. © Springer International Publishing Switzerland 2016, http://www.cs.amedd.army.mil/borden/book/ccc/UCLAchp4.pdf, Firefighter Regional Burn Center at the Elvis Presley Memorial Trauma Center, https://doi.org/10.1007/978-3-319-16586-8_15. 2006;60:432–42. Basic principles of damage control surgery Definition of damage control surgery. J Trauma. Prehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury: a randomized controlled trial. Positioning the patient is dependent on which cavities or extremities need to be explored as previously determined in the emergency department. Andriessen TM, Horn J, Franschman G, van der Naalt J, Haitsma I, Jacobs B, et al. Upon arrival to the room, the surgeon may give the team a brief history, interventions undertaken thus far, lines and tubes in place or needed, and the overall plan for the operation. Field hypotension in patients who arrive at the hospital normotensive: a marker of severe injury or crying wolf? Once the endovascular team is available, the surgeon and radiologists can work together to combine operative and endovascular interventions to stop bleeding. (2019) Garcia et al. The goal of Part 2 is to continue aggressive resuscitation in a rapid fashion in order to correct the physiologic derangements. Radiology technicians can be at the bedside waiting with portable X-rays and can expedite any other radiological interventions such as computed tomography (CT). Bladder pressures should be measured frequently or even continuously. If the patient’s bleeding is controlled upon arrival, the primary and secondary surveys should be rapidly conducted in the usual fashion, and the four remaining cavities assessed for hemorrhage with the usual adjuncts. This will be discussed further in Chap. 2011;28:2019–31. Damage control surgery can be divided into the following three phases: Initial laparotomy, Intensive Care Unit (ICU) resuscitation, and definitive reconstruction. 2008;64:S28–37. The optimal strategy for managing hemorrhaging trauma patients is now termed damage control resuscitation (DCR) (Table 1). Schwartz's Principles of Surgery, 10e Brunicardi F, Andersen DK, Billiar TR, Dunn DL, Hunter JG, Matthews JB, Pollock RE. Schenarts PJ, Phade SV, Agle SC, Goettler CE, Sagraves SG, Newell MA, et al. Authors; Authors and affiliations; Fredric M. Pieracci; Ernest E. Moore; Chapter. Patients with non-compressible hemorrhage sources receive the highest priority for immediate transport to a hospital. Damage control sequence. Scand J Surg. Depending on patient stability and resource availability, the team may elect to obtain a CT to gain further information. Fearnside MR, Cook RJ, McDougall P, McNeil RJ. Damage control Laparotomy 18 Principles • Control haemorrhage operative control of haemorrhage and simultaneous vigorous resuscitation with blood and clotting factors Availability of Blood, FFP, cryoprecipitate, platelet • Prevention contamination • Avoid further injury • … Accessed on 22 Jan 2013 from. Jankovic - Free download as Powerpoint Presentation (.ppt), PDF File (.pdf), Text File (.txt) or view presentation slides online. The use of temporary vascular shunts as a damage control adjunct in the management of wartime vascular injury. 2018 Apr;42(4):965-973. Needle decompression or tube thoracostomy may be performed for hypoxia and loss of breath sounds. All injuries must be fully exposed to localize hemorrhage and contamination. 1997;19:633–45. Surgery may be considered if the spinal cord is compressed and when the spine requires stabilization. Arrangement of Emergency Department resuscitation area conducive to effective communication. Author information: (1)Department of Surgery, Division of Trauma/Critical Care, University of South Alabama Medical Center, Mobile, AL 36617, USA. Note that the Recorder is adjacent to the Team Leader to read back information. J Trauma. In addition to the trauma, hemorrhage and tissue hypoperfusion, a secondary systemic injury, by inflammatory mediator release, contributes to acidosis, coagulopathy, and hypothermia and leads to multi system organ failure. Once a cavity is opened, hematoma and blood should be evacuated (usually manually) and the cavity packed with lap sponges. Mil Med. The term “damage control” refers to a specific approach to the exsanguinating trauma patient. The LITFL page on damage control surgery is an excellent introduction to the subject. ... is the most common indication for damage control surgery. Pape HC, Giannoudis P, Krettek C. The timing of fracture treatment in polytrauma patients: relevance of damage control orthopedic surgery. If a liver injury or pelvic fracture with bleeding is found, the team may proceed to a hybrid operating and endovascular room (when available) to control hemorrhage operatively while mobilizing the endovascular team. It is a staged strategy for the treatment of severe bleeding injury occurring from either blunt or penetrating mechanisms . Temporary vascular continuity during damage control: intraluminal shunting of proximal superior mesenteric artery injury. The use of quantitative end-tidal capnometry to avoid inadvertent severe hyperventilation in patients with head injury after paramedic rapid sequence intubation. 1998;68:826–9. 2006;171:352–6. If at any point during Part 2 the acidosis or coagulopathy is not correcting or was trending in the correct direction, but then regresses, or if there is clinical evidence of ongoing, rapid hemorrhage, the patient should be immediately returned to the operating room as this is indicative of a missed injury or ongoing, uncontrolled bleeding. In the event of persistent hypoxemia, lung protective strategies such as ARDSNet ventilation should be implemented. 2003;54:307–11. The concept has been expanded from the operative technique to principles underlying the logistical flow of a trauma patient from the scene through the emergency department to the operating room then ICU for resuscitation, and back to the OR for definitive repair. Ann Surg. Most vessels may be ligated. Damage control resuscitation (DCR) is a strategy for resuscitating patients from hemorrhagic shock to rapidly restore homeostasis. Stone HH, Strom PR, Mullins RJ. Damage control surgery concept (DCS) consists of performing a staged surgery and allowing resuscitation in severe trauma patients who require surgical management. World Journal of Emergency Surgery. Management of the major coagulopathy with onset during laparotomy. NTLHE. Fractures can be splinted to provide stability and decrease ongoing bleeding. “Damage Control”: an approach for improved survival in exsanguinating penetrating abdominal injury. [1–25] Damage control resuscitation seeks to minimize blood loss until definitive hemostasis is achieved. damage control Each of these phases has defined timing and objectives to ensure best outcomes. Background: Tractotomy has become the standard of care for transfixing through-and-through lung injuries as it can be performed quickly with little blood loss and a low risk of complications. To implement damage control and salvage a severely injured patient, the team—EMS, emergency department personnel, surgeons, and ICU staff—must recognize patients that benefit from damage control and effectively communicate to ensure smooth transitions through the hospital system while providing quality care in each setting. Special lessons learned from Iraq. 1996;40:764–7. Bernard SA, Nguyen V, Cameron P, Masci K, Fitzgerald M, Cooper DJ, et al. 159.89.172.72. Victims of major trauma suffer from a worsening physiologic derangement manifested by the triad of acidosis, hypothermia and coagulopathy. J Neurotrauma. J Orthop Trauma. Stocchetti N, Furlan A, Volta F. Hypoxemia and arterial hypotension at the accident scene in head injury. 1999;25:805–13. Tourniquet use on the battlefield. However, the ability to evaluate objectively the differences and then cho… Mr John Taylor. Despite this reality, indications for initiating DCS remain debated. Core temperature should be monitored and rewarming measures such as blankets and warmed fluids used because hypothermia can inactivate the clotting cascade and impede the body’s ability to coagulate blood. Again, communication with bed control to ensure an ICU bed is available and with the ICU nurses and physicians eases the transition to the next stage of damage control. If these goals are met, isotonic crystalloid may be used, but be mindful that normal saline may lead to a non-anion gas metabolic acidosis, worsening coagulopathy. The use of spanning external fixation, antibiotic bead pouches 118 - 120 ( Figs. Beekley AC, Sebesta JA, Blackbourne LH, Herbert GS, Kauvar DS, Baer DG, et al. Acute respiratory distress syndrome (ARDS) and transfusion-related acute lung injury (TRALI) can result from aggressive resuscitation and blood product administration. Mabry RL. 2007;12:S1–52. The cavity should be thoroughly explored. Phelan HA(1), Patterson SG, Hassan MO, Gonzalez RP, Rodning CB. 2007;62:S36–7. Mil Med. Large-bore IVs should be placed, and resuscitation begun with isotonic crystalloid. The goal of damage control surgery is to recognize patients who are physiologically deranged, need second explorations, or are at risk for complications if the traditional approach with closure is undertaken. If multiple cavities are left open in Part 1, all cavities may be closed in Part 3 or only one and Part 3 repeated for each cavity. Part of Springer Nature. Early injury and physiologic pattern recognition The ultimate goal of each strategy is to implement the damage control concept early in care, combat the lethal triad, and transport victims safely for definitive management. 1997;42:559–61. Blast injuries can create penetrating wounds from shrapnel, but can throw a patient with great force, causing blunt injuries as well. Advanced burn life support manual. Stannard A, Eliason JL, Rasmussen TE. Eiseman B, Moore EE, Meldrum DR, Raeburn C. Feasibility of damage control surgery in the management of military combat casualties. Should a patient arrest just prior to arrival or in the resuscitation bay, an emergent resuscitative thoracotomy may be performed to release a cardiac tamponade and/or occlude the aorta in order to maintain perfusion to the heart and brain. The need for good decision making abounds in a trauma laparotomy, and the principles of hemorrhage control followed by contamination control with attention to coagulation physiology should help direct the surgeon. For extremities, a Stryker needle can be used to objectively quantify the pressure; rapid, significant increases in compartment pressures, a measured compartment pressure >30 mmHg, or <30 mmHg difference in the diastolic blood pressure and measured compartment pressure should prompt fasciotomies. The ipsilateral arm is abducted at 90° and elbow flexed at 30°. Most importantly, roles during the triage are assigned and performed in an organized manner. Identification of patients who benefit from damage control surgery is an art that requires experience and communication. Ukai T. The great Hanshin-Awaji earthquake and the problems with emergency medical care. Brenner ML, Moore LJ, DuBose JJ, Tyson GH, McNutt MK, Albarado RP, et al. 1993;7:267–79. Extremity vascular injuries on the battlefield: tips for surgeons deploying to war. Tourniquet use in combat trauma: UK military experience. This often leads to a vicious cycle … Damage control surgery is defined as rapid termination of an operation after ... Damage control principles can be applied to all disciplines of trauma care. 2002;183:622–9. 2014;21:163–73. Hemorrhage is the leading cause of preventable death on the battlefield. Damage Control Resuscitation. The primary objectives of damage control laparotomy are to control bleeding and limit GI spillage. Int Care Med. Marmarou A, Anderson RL, Ward JD, et al. The principles of damage control surgery were applied in the cases of three severely injured multitrauma patients, men aged 47 and 33 years who had a motorcycle accident and a 66-year-old man who had a car crash. If a vascular injury is suspected, both legs from the inguinal ligament to knees should be prepped in case vein graft is needed. Principles of resuscitation and damage control in abdominal emergencies. The term “damage control” refers to a specific approach to the exsanguinating trauma patient. The blood bank can be notified if a massive transfusion is planned in order to begin thawing products. Chambers LW, Green DJ, Sample K, Gillingham BL, Rhee P, Brown C, et al. Restoration of bowel continuity, definitive debridement and wound closure are all deferred until physiology is optimised. Damage control Laparotomy 18 Principles • Control haemorrhage operative control of haemorrhage and simultaneous vigorous resuscitation with blood and clotting factors Availability of Blood, FFP, cryoprecipitate, platelet • Prevention contamination • Avoid further injury • Evacuation of blood. Not logged in Prehosp Emerg Care. A clinical series of resuscitative endovascular balloon occlusion of the aorta for hemorrhage control and resuscitation. Preventing renal failure in patients with rhabdomyolysis: do bicarbonate and mannitol make a difference? In some instances, time will only permit splash prep. J Trauma. Damage control surgery refers to limited surgical interventions that serve to control haemorrhage and minimize contamination until the patient has sufficient physiological reserve to undergo definitive interventions. J Neurosurg. The patient is primarily supine, but on the ipsilateral side of the thorax to be entered, the chest wall is rotated medially about 30° to the coronal plane and supported with a roll. 2004;56:1191–6. 2010;252:959–65. J Trauma. The ordered scans should be discussed and clarified. A full laboratory panel should be sent upon arrival to the ICU including a complete blood count (CBC) with differential, complete metabolic panel (CMP) with all electrolytes, creatine kinase (CK), lactic acid (LA), arterial blood gas (ABG), and coagulation panel including fibrinogen and repeated at minimum every 4–6 h (up to every 1–2 h in certain circumstances) to guide resuscitation and organ perfusion endpoints. Angiography before damage control laparotomy may also be indicated if there is Damage control surgery. This phase of damage control occurs in the prehos-pital and trauma admission areas of the hospital. The Westmead Head Injury Project outcome in severe head injury. Arch Surg. 2001;166:490–3. A patient may exsanguinate externally or internally (thorax, abdomen, pelvis, retroperitoneum, soft tissues). Bochicchio GV, Ilahi O, Joshi M, Bochicchio K, Scalea TM. Serial troponins and electrocardiograms may also be included. Girard E, Abba J, Boussat B, Trilling B, Mancini A, Bouzat P, Létoublon C, Chirica M, Arvieux C World J Surg. hphela@yahoo.com PMID: 17116562 [Indexed for MEDLINE] Arch Surg. Johnson JW, Gracias VH, Schwab CW, Reilly PM, Kauder DR, Shapiro MB, et al. Porter JM, Ivatury RR, Nassoura ZE. The principles of damage control surgery and resuscitationlisted below are of tantamount importance for the care of the patientwho is hypothermic, coagulopathic, acidotic, and resistant to fluidresuscitation. A trauma cart with basic supplies (shunts, staplers, tubes, drains, vacuum dressings) and various trays (vascular, thoracotomy, laparotomy) as well as a trauma suture tree should already be available in the room or just outside. Surgery Depending on the circumstances, when surgery is required, it may be performed within 8 hours following injury. 2001;51:261–9. Hemorrhage sites are either anatomically compressible (e.g., extremity, or axillary/groin vascular injuries) or completely non-compressible (e.g., truncal injuries). hphela@yahoo.com PMID: 17116562 [Indexed for MEDLINE] 1 damage control resuscitation (DCR) emerged as an extension of a principle used by trauma surgeons called damage control surgery (DCS), which limits surgical interventions to those which address life-threatening injuries and delays all other surgical care until metabolic and physiologic derangements … Lakstein D, Blumenfeld A, Sokolov T, Lin G, Bssorai R, Lynn M, et al. Etomidate versus ketamine for rapid sequence intubation in acutely ill patients: a multicenter randomized controlled trial. Necessary equipment can be gathered and procedure trays opened. Coagulopathy is common in patients with haemorrhagic shock. Ann Surg. 1983;197:532–5. Generally, the trauma patient is supine with both arms abducted at 90° and prepped from chin to knees and laterally to the bed. PRINCIPLES OF DAMAGE CONTROL IN TRAUMA: 18th Annual Controversies and Problems in Surgery DEPARTMENT OF SURGERY SBAH/UP TORSO TRAUMA L.M. In abdominal surgery, “damage control” refers to those maneuvers designed to ensure patient survival. J Trauma. Damage control surgery (DCS) is a concept of abbreviated laparotomy, designed to prioritize short-term physiological recovery over anatomical reconstruction in the seriously injured and compromised patient. Author information: (1)Department of Surgery, Division of Trauma/Critical Care, University of South Alabama Medical Center, Mobile, AL 36617, USA. This surgery should follow DCS principles and may include surgery for proximal haemorrhage Practical use of emergency tourniquets to stop bleeding in major limb trauma. 157 Accesses. 2006;61:8–15. Damage control surgery. Thoracic damage-control operation: principles, techniques, and definitive repair. J Trauma. Previously, 2 l of isotonic crystalloid were given followed by either more crystalloid or blood products if available to achieve a desired response in vital signs. Jankovic - Free download as Powerpoint Presentation (.ppt), PDF File (.pdf), Text File (.txt) or view presentation slides online. 2013;75:506–11. A critical judgment to be made by the surgeon is that of the operative profile: damage control versus definitive repair. While a trauma-ready operating room is always available at a Level 1 center, the lights can be turned on, the room and bed warmed, and the nurse, scrub technician, and anesthesia team mobilized to prepare for a case. Cricothyroidotomy may be necessary with a blast to the face. Holcomb JB, Helling TS, Hirschberg A. While the resuscitation ratio is debated, a 1:1 or 1:2 ratio of packed red blood cells (pRBCs) to fresh frozen plasma (FFP) is the current recommendation. Over the last two decades, public health measures and better pre-hospital care have led to an increasing number of seriously injured patients surviving their initial accident and arriving in hospital.1These injured patients often have injuries to multiple body cavities, massive haemorrhage, and near exhausted physiological reserve. Principles and Philosophy of Damage Control Surgery. China: Elsevier, Inc.; 2012. Clinically, urine output may be measured and stabilization in vital signs with titration of pressors off is indicative that end-organ perfusion is being achieved. American Burn Association. 2000;135:1323–7. Thoracic damage-control operation: principles, techniques, and definitive repair. 2004;56:808–14. This is a preview of subscription content. Prehospital tourniquet use in operation Iraqi freedom: effect on hemorrhage control and outcomes. Another important role of the ICU provider is to perform a thorough tertiary survey including physical examination and review of pertinent imaging and blood work to ensure that no injuries or wounds have been missed. The principles of damage control surgery are ; Control haemorrhage ; Prevention contamination ; Avoid further injury; 12. This webinar aimed at medical undergraduates will provide an outline of the principles and practice of damage control resuscitation and surgery. Davis DP, Peay J, Sise MJ, Kennedy F, Simon F, Tominaga G, et al. Some centers place the operating room (OR) staff on standby when the trauma team is activated in the emergency department. J R Army Med Corps. 2003;54:S221–5. Purpose of review Damage control surgery (DCS) has become a lifesaving maneuver for critically injured patients when utilized in appropriate scenarios. 2004;57:1–10. 2006;86:711–26. Prior to closing the abdomen, an X-ray should be obtained and confirmed with radiology that no foreign bodies remain in the cavity. 2011;15:184–92. INTRODUCTION 9 introduction Facing the challenges One night while on duty Dr X, an experienced surgeon working in an ICRC field … When proceeding to the operating room, the staff should be told to obtain a sterile pneumatic tourniquet and prepare for abdominal and extremity exploration and temporary dressings. 1 damage control resuscitation (DCR) emerged as an extension of a principle used by trauma surgeons called damage control surgery (DCS), which limits surgical interventions to those which address life-threatening injuries and delays all other surgical care until metabolic and physiologic derangements have been treated. 53 countries, distributed on every continent Controversies and problems in surgery department of surgery TORSO. 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