Professional Documents
Culture Documents
Correspondence to
Prof. Brian J Rowlands,
Section of Surgery,
Queen's Medical Centre,
University Hospital,
Nottingham
NG7 2UH, UK
Damage control
The acceptance by trauma surgeons of the 'abbreviated' or 'damage
control' laparotomy has been a significant development in surgery for
abdominal injury. It is not a new concept to terminate operative
procedures for a deteriorating patient to allow further resuscitation and
845
Trauma
Adverse effects
>15 mmHg
> 30 mmHg
847
Trauma
848
Interventional radiology
849
Trauma
'Grade
Injury description
Haematoma
Laceration
II
Haematoma
Laceration
III
Haematoma
Laceration
Laceration
Laceration
Vascular
scaled from I to VI that differs from the Injury Severity Score as it is not
intended to correlate with anticipated patient outcome. The grades
represent increasingly complex injuries and grade VI is reserved for
injuries that are beyond repair and are incompatible with survival. The
majority of institutions dealing with trauma on a regular basis have
uniformly accepted this scheme. The organ injury scales provides a
common descriptive language for the comparison of technique and results
between organisations. The organ injury scales for splenic and duodenal
injuries are reproduced in Tables 2 and 3 27 .
Table 3 Duodenum injury scale
Grade
'Grade
Injury description
Haematoma
Laceration
II
Haematoma
Laceration
III
Laceration
IV
Laceration
Laceration
Vascular
850
IV
Current debate
Abdominal assessment and investigation
In Europe and the US, ultrasound has become the main investigation for
blunt abdominal trauma and is most useful in detecting injury to solid
British Medical Bulletin 1999,55 (No 4)
851
Trauma
Computerised tomography
Diagnostic laparoscopy
853
Trauma
References
1
2
3
4
5
6
10
11
12
13
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23
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25
854
The Royal College of Surgeons of England. The management of patients unth major injuries. A
report of a working party of The Royal College of Surgeons of England. London: The Royal
College of Surgeons, 1988
Stone HH, Strom PR, Mullins RJ. Management of the ma|or coagulopathy with onset during
laparotomy. Ann Surg 1983, 197: 532-5
Rotondo MF, Schwab CW, McGonigal MD et al. 'Damage control': an approach for improved
survival in exsanguinating penetrating abdominal injury. / Trauma 1993; 35. 375-83
Burch JM, Ontz V, Richardson RJ, Martin RR, Mattox KL, Jordan GL. Abbreviated laparotomy
and planned reoperation for critically in)ured patients Ann Surg 1992; 215: 476-83
Ferrara A, MacArthur JD, Wright HK et al Hypothermia and acidosis worsen coagulopathy in the
patient requiring massive transfusion. Am J Surg 1990; 160: 515
Burch JM, Denton JR, Nobel RD. Physiologic rationale for abbreviated laparotomy. Surg Chn
North Am 1997; 77: 779-82
Jurkovich GJ, Greiser WB, Luterman A, Curreri PW Hypothermia in trauma victims an ominous
predictor of survival / Trauma 1987, 27: 1019-24
Cosgnff N, Moore EE, Sauaia A, Kenny-Moynihan M, Burch J, Galloway B Predicting life
threatening coagulopathy in the massively transfused trauma panent: hypothermia and acidoses
revisited. / Trauma 1997, 42 857-62
Fehciano DV, Moore EE, Mattox KL Damage control and alternate wound closures in abdominal
trauma. In Fehciano DV, Moore EE, Mattox KL (Eds) Trauma, 3rd edn. Stamford, CT: Appleton
& Lange, 1996, 717-32
Burch JM. New concepts in trauma. Am] Surg 1997; 173 44-6
Sugrue M, Buist MD, Hounhan F, Deane S, Bauman A, Hillman K. Prospective study of mtraabdominal hypertension and renal function after laparotomy. Br J Surg 1995, 82 2358
Fernandez L, Norwood S, Roettger R, Wilkins HI HE, Temporary intravenous bag silo closure in
severe abdominal trauma. / Trauma 1996, 40: 258-60
Baron BJ, Scalea TM, Sclafani SJ et al. Non operative management of blunt abdominal traumathe role of sequential diagnostic peritoneal lavage, computed tomography and angiography Ann
Emerg Med 1993, 22. 1556-62
Sclafani SJ, Shaftan GW, Scalea TM et al. Non-operative salvage of computed tomography
diagnosed splenic injuries- utilization of angiography for triage and embolizanon for hemostasis. /
Trauma 1995; 39- 818-27
Mucha P, Daly RC, Farnell MB. Selective management of blunt splenic trauma. / Trauma 1986,
26 970-9
Becker CD, Spring P, Glattdi A, Schweizer W. Blunt splenic trauma in adults: can CT findings be
used to determine the need for surgery? Am J Roentgenol 1994; 162: 3437
Kohn JS, Clark DE, Isler RJ, Pope CF Is computed tomographic grading of splenic in)ury useful in
the nonsurgical management of blunt trauma? / Trauma 1994; 36 385-9
Smith Jr JS, Wengrovitz MA, Delong BS. Prospective validation of criteria, including age, for safe,
non surgical management of the ruptures spleen. / Trauma 1992; 33: 363-8
Carnllo EH, Platz A, Miller FB, Richardson JD, Polk Jr HC. Non operative management of blunt
hepatic trauma. Br } Surg 1998, 85. 461-8
Thaemert BC, Cogbill TH, Lambert PJ Nonoperanve management of splenic injury: are follow up
computed tomographic scans of any value. / Trauma 1997, 43 748-51
Losty PD, Okoye BO, Walter DP, Turnock RR, Lloyd DA. Management of blunt liver trauma in
children Br ] Surg 1997; 84: 1006-8
Keller MS, Stafford PW, Vane DW. Conservative management of pancreatic trauma in children /
Trauma 1997, 42- 1097-1100
Denton JR, Moore EE, Coldwell DM. Multimodality treatment for grade 5 hepatic injuries
'penhepanc packing' arterial embohzation, and venous stenting. / Trauma 1997, 42: 964-8
O'Neill, Riina J, Scalafani S, Tornetta 3rd P. Angiographic findings in pelvic fractures. Cltn Orthop
1996; 329: 60-7
Sclafani AP, Sclafani SJ. Angiography and transcatheter arterial embolisaoon of vascular injuries
of the face and neck Laryngoscope 1996; 106. 168-73
855
26 Sclafatu SJ, Scalea TM, Wetzel W et al. Internal carotid artery gunshot wounds. / Trauma 1996,
40 751-7
27 Moore EE, Cogbill TH, Malangoni MA et al. Organ injury scaling Surg Citn North Am 1995; 75:
293-303
28 Root HD, Hauser CW, McKinley CR, Lafave JW, Mendjola RP. Diagnostic pentoneaJ lavage
Surgery 1965, 57, 633-7
29 Fehciano DV. Diagnostic modalities in abdominal trauma. Peritoneal lavage, ultrasonography,
computed tomography scanning and artenography Surg Clm North Am 1991; 71: 241-56
30 Powell DC, Bivins BA, Bell RM. Diagnostic peritoneal lavage. Surg Gynecol Obstet 1982; 155:
257-64
31 Velmahos GC, Demetnades D, Stewart M et al Open versus closed diagnostic peritoneal lavage:
a comparison on safety, rapidity, efficacy ] R Coll Surg Edtnb 1998, 43: 235-8
32 Cue JL, Miller FB, Cryer 3rd HM, Malangoni MA, Richardson JD A prospective, randomized
comparison between open and closed peritoneal lavage techniques. / Trauma 1990; 30: 880-3
33 Forster R, Pillasch J, Zielke A, Malewski U, Rothmund M. Ultrasonography m blunt abdominal
trauma: influence of the investigator's experience / Trauma 1992; 34: 2649
34 Rozycki GS, Oschner MG, Jarfin JH, Champion HR Prospective evaluation of surgeons' use of
ultrasound in the evaluanon of trauma patients. / Trauma 1993, 34: 516-26
35 Boulanger BR, Brenneman FD, McLellan BA, Rizoli SB, Culhane J, Hamilton P A prospective study
of emergent abdominal sonography after blunt abdominal trauma. / Trauma 1995; 39: 325-30
36 McKenney MG, Martin L, Lentz K et al. 1000 consecutive ultrasounds for blunt abdominal
trauma. / Trauma 1996; 40: 607-12
37 Rozycki GS, Shackford SR. Trauma ultrasound for surgeons In: Staren ED (Ed) Ultrasound for
the Surgeon. New York Lippincott-Raven, 1997; 120-35
38 Clancy TV, Ragozzino MW, Ramshaw D, Churchill MP, Covington DL, Maxwell JG. Oral
contrast is not necessary in the evaluation of blunt abdominal trauma by computed tomography.
Am] Surg 1993; 166: 680-5
39 Sutyak JP, Chiu WC, D'Amelio LF, Amorosa JK, Hammond JS. Computed tomography is
inaccurate in estimating the seventy of adult splenic in)ury. / Trauma 1995, 39. 514-8
40 Catre MG. Diagnostic peritoneal lavage versus abdominal computed tomography in blunt
abdominal trauma: a review of prospective studies Can] Surg 1995; 38 117-22
41 Sherck JP, Oakes DD. Intestinal in|unes missed by computed tomography / Trauma 1990, 30: 1-7
42 Ahkrass R, Kim K, Br.mdt C Computed tomography: an unreliable indicator of pancreanc
trauma Am Surg 1996; 62: 647-51
43 Leppaniemi AK, Ellliot DC. The role of laparoscopy in blunt abdominal trauma Ann Med 1996;
28 483-9
44 Salvino CK, Esposito TJ, Marshall WJ, Dries DJ, Morns RC, Gamelh RL. The role of diagnostic
laparoscopy in the management of trauma patients a preliminary assessment ] Trauma 1993; 34:
506-15
45 Townsend MC, Flancbaum L, Choban PS, Cloutier CT Diagnostic laparoscopy as an adjunct to
selective conservative management of solid organ injunes after blunt abdominal trauma. / Trauma
1993; 35: 647-51
46 Brooks AJ, Boffard KD Current technology laparoscopic surgery in trauma Trauma 1999, 1.
53-60
47 Liu M, Lee CH, P'eng FK. Prospective companson of diagnostic pentoneal lavage, computed
tomographic scanning and ultrasonography for the diagnosis of blunt abdominal trauma. /
Trauma 1993; 35: 267-70
48 Zantut LF, Ivatury RR, Smith S et al. Diagnostic and therapeutic laparoscopy for penetrating
abdominal trauma: A multicenter expenence / Trauma 1997; 42: 825-31