Department of Coloproctology, Main Military Clinical Hospital,

Moscow, Russia,

Department of Orthopedics and Trauma Surgery, Aachen University Medical Center, 

Aachen, Germany,

Department of Surgery, University of Pittsburgh, 

Pittsburgh, USA

 

Early Total Care (ETC) approach was suggested by surgeons, in which surgical intervention of all trauma patients were performed within the first 24 hours after trauma despite the area and severity of injuries[1, 2].Accordingly, the ETC approach became the “gold standard” of trauma care. In this context, a triple randomized study by L.B. Bone et al. in 1989 covering 178 hip fracture patients with early (in the first 24 hours ) and late osteosynthesis revealed lower incidence of pulmonary complications (pneumonia, and adult respiratory distress syndrome (ARDS)) as well as shorter duration of shock in patients who applied on the ETC approach. However, with further development in field of trauma care, beneficial outcomes of the ETC approach started to become questionable, as a metacentric study of 1,127 patients with multiple injured area of chest and extremities showed that patients at age of 20-30 years with traumatic shock, and without concurrent conditions after primary osteosynthesis were more prone to pulmonary complications through the first 24 hours post-injury [3]. This study pointed out the wounded patients in the borderline state with unstable hemodynamic parameters, which was referred to as “the borderline era” [4, 5].

Nowadays, damage control (DC) approach is successfully applied in the post-traumatic surgical interventions of the chest, abdomen, pelvis, extremities, vessels, and urinary system organs [6-14] in the civilian and military services. Surgeons start to use the DC approach under the field conditions. First, the indications for applying this surgical technique were based on the civilian doctors’ experience; then indications started to be formed with regard to warfare and changing tactical conditions. In this study we sought to examine the differences in applying the damage control (DC) approach in specialized traumatology center and a military field hospital.

 

 

Damage Control Surgical Approach Indications in Civilian Trauma Patients

DCS approach help in restoring the pathophysiological changes in trauma patients. Applying such approach in civilian trauma patients depends on the equipment availability, and patient’s physiologic conditions. Outcomes of injury following trauma depend on the extent of injury, the host’s attendant inflammatory and pathophysiologic responses, as well as timely care[15].In this context, surgical intervention can enlarge the degree of damage from primary trauma leading to substantial increase in the morbidity and mortality risks[10], while timing of surgical intervention can significantly affect the final outcomes for trauma patients.

Trauma Patients can be categorized into 4 groups (stable, borderline, unstable, and in extremis conditions) in order to direct the appropriate treatment approach (Fig. 1). Stable condition patients are hemodynamically stable, respond to initial fluid therapy, and without any evidence of respiratory disorders, coagulopathy, hypothermia, and abnormalities of acid base status. In addition, stable condition patients without comorbidities usually tolerate early definitive strategy[16, 17]. Moreover, borderline conditions patients need invasive monitoring pre-operatively, can be treated operatively but with cautious, and with the first sign of deterioration, conversion to a “damage control” approach should be performed. Furthermore, unstable condition patients are hemodynamically unstable, at risk of rapid deterioration, multiple organ failure, and death. In these patients, the “damage control” approach is required. This entails rapid lifesaving surgery only when absolutely necessary and timely transfer to the intensive care unit for further stabilization and monitoring. Finally, in-extremis condition patient, ongoing uncontrolled blood loss without response to resuscitation, suffer the effects of four vicious cycles: coagulopathy, shock, hypothermia, and tissue injury.  These patients need direct transfer to the intensive care unit for invasive monitoring and advance hematologic, pulmonary, and cardiovascular support.

Figure 1

Poly-trauma patients are assessed according to the Advanced Trauma Life Support (ATLS) approach.  Next, classification (stable, borderline, unstable, in-extremis) of the trauma patients is performed using clinical parameters. In “stable” patients a safe definitive surgery (SDS) strategy can be applied. The patients “in extremist” should be transferred directly to the intensive care unit for invasive monitoring and advanced hematologic, pulmonary, and cardiovascular support. “Borderline” and “unstable” patient are brought to the ICU department for resuscitation. Thereafter, re-evaluation of the clinical status is performed. In “unstable” patients and “borderline” patients with secondary deterioration should be treated according to the damage control orthopedics (DCO) concept. Patients with improving conditions can be subjected to safe definitive surgery

Damage Control Surgical Approach Indications in Military Field

Under field conditions, the importance of DCS approach is a mass delivery of the wounded patients within a short time period into one medical center, whereas, in civilian conditions, the flows of injured patients may be allocated between several medical centers. Beside the pathophysiological parameters, a military surgeon also should have a personal professional capabilities and skills to repair all injuries single-step. Due to the difficulty in repairing all injuries at once; changes in the military medical situation were required to switch from general-practice field surgeon to specialized surgical interference[18].In this context, mass delivery of injured patients at warfare depends mainly on the decision-making needed time, which in some cases there is no time to wait for biochemical blood values of the wounded patients, as one or two criteria will be enough for decision making: decrease in systolic pressure below 90 mmHg, lactate levels below 7.5 mmol/L, and body temperature drop below 35.5°Ñ [19].

 

Initial Management

In general, there are no differences in the techniques used during the initial assessment/treatment between military field hospital and a civilian trauma center. However, in setting of military field hospital, urgent surgeries are performed to control active bleeding, fix unstable bone fragments, prevent infection spread to hollow organs, and to control respiratory failure causes. Moreover, initial treatment of severely injured patients requires anticipation of potential complications and appropriate time for surgical interventions using a systematic approach [20].

Post-traumatic course can be classified in to 4 phases: acute phase (1-3 h); primary phase (1-48 h); secondary period (2-10 days); and tertiary period (weeks to months after trauma).

1.      Acute phase (1-3 hours after admission): Resuscitation /Hemorrhage Control

The focus of management plan is to control the acute life threatening conditions, this involves airway control, thoracentesis, rapid control of external bleeding, and fluid/blood replacement. Blunt trauma to trunk (thorax and abdomen), and extremities is known to be of immense importance for the clinical course of severely injured patients [21], as those patients need to be assessed for “four pathophysiologic cascades” (hemorrhagic shock, coagulopathy, hypothermia, and soft tissue injuries) which results in endothelial damage [21], in order to avoid any life-threatening systemic complications (Fig. 2):

·         Hemorrhagic Shock: The systolic blood pressure, dependence on vasopressors, and low urine output are reliable clinical markers of hypovolemia.

·         Coagulopathy: Low platelet count is a reliable marker for the post-traumatic coagulopathy disorder, which can indicate impending disseminated intravascular coagulation (DIC). Studies have shown that decreased systemic platelet count (below 90,000/ml) on the first day post-injury was associated with higher incidence of multiple organ failures and deaths [22, 23]. Correction of hypothermia and acidosis facilitate the recovery of coagulopathy as well as recombinant factor VIIa (rFVIIa). High effectiveness is noted for using, at warfare, of whole fresh blood as compared to transfusion of 1 dose of fresh-frozen plasma, 1 dose of thrombocytes and 1 dose of cryoprecipitate, being conditioned by higher hematocrit concentration (38-44 % against 29 %), platelet count (150,000-400,000/mm³ against 87,000/mm³), fibrinogen content (1,500 mg against 750 mg), and coagulated activity (100 % against 65 %)[24].

·         Hypothermia: Body temperature below 33°C has been described to be a critical value [25], as patients presenting with hypothermia are more prone to develop cardiac arrhythmia, cardiac arrest, and coagulopathy. 

·         Soft tissue injury: This category includes crush injuries, severe pelvic fractures, and thoracic and abdominal trauma (AIS >2), which affect the inflammatory response post-injury through stimulation for the immune system, and eventually development of the systemic inflammatory response syndrome (SIRS).

Figure 2

Four vicious cycles demonstrate the pathophysiological cascades.  These are known to be associated with the development of post-traumatic immune dysfunction and the endothelial damage. The exhaustion of the compensatory mechanisms results in development of systemic complications

2.      Primary phase (1-48 hours after admission): Fractures Stabilization

Major injuries are managed in the primary phase, as the evacuation of the injured or the wounded patients to the following treatment echelon must be performed within this period. This phase includes acute stabilization of major extremity fractures associated with arterial injuries and compartment syndrome, in which fractures can be temporally stabilized by external fixation and the compartments released where appropriate. Systemic complications, such as development of systemic inflammatory response syndrome (SIRS), and acute lung injury (ALI) need to be considered if major musculoskeletal injuries are present.

Under civilian conditions, the injured patients are examined by single-discipline doctors and, specialists (ophthalmologist, neurosurgeon, and vascular surgeon), accordingly the management plan is determined. However, in the military field hospitals, such algorithm is not always possible, for that it is extremely important to evacuate the wounded patients in time from the military field hospital to rear medical facilities. When comparing different conditions at this stage, we noticed that differences between the military and civilian patients in regard to the arrangement of medical care [26-29].

 

3.      Secondary period (2-10 days after trauma): Regeneration

During the secondary phase the patients’ general condition are stabilized by 2-4 days after trauma and monitored through the physiological and intensive care scoring system. Surgical interventions should be limited to those absolutely required (“second look”, or debridement), and lengthy procedures should be avoided.

4.      Tertiary period (weeks to months after trauma): Reconstruction &Rehabilitation

During the tertiary phase, patients are able to have the definitive fracture stabilization. Intensive rehabilitation help maintaining range of motion, improve functional outcomes, social reintegration, and return to work.

Distinct Injury Patterns

Most common mechanisms of fatal injuries in civilian trauma patients are MVAs, falls, and penetrating injuries (stabbing or shooting), while still the cranial injuries conceder the most common causes of death, followed by exsanguination in trauma. Goris et al. [30] revealed in his study that early (1 hour post-admission up to 24 hours post-injury), and through the first week deaths were due to brain injuries. While, hemorrhage and severe bleeding after thoracic and abdominal injuries, was the second frequent cause in the early death group [31]. However, sepsis and multi-organ failure were less frequent in the early phase post-injury, while predominant in the late phase (> 1 week) [30, 32-36]. Finally, other causes of injury in civilian trauma patients should keep in mind; catastrophes, natural disasters, and terrorist attacks which are less common, and morphologically similar to battle wounds.

Development of medical technology, means of protection for military men, improvement of medical service, and evacuation facilities led to significant increase in the number of wounded patients that are promptly delivered to military field hospitals. Moreover, the seriously wounded to the lightly wounded ratio has changed in favor of the first ones [37]. The structure of injuries in warfare and civilian setting differs, as battle traumas are more prone to penetrating trauma because of mine-explosive, fragment and bullet wounds. The epidemiological character of gunshot injuries varies, depending on the place of warfare (onshore, sea, air) and, the conditions (southern or northern countries). From the times of World War II to the conflicts in Afghanistan, Iraq, and North Caucasus, the structure of the wounded patients changed considerably (Table 1). Studies showed an increase in the number of head (2-2.5 times), and abdomen injuries (1.5-2 times) [38].

 Table 1

Comparison of delivery time of wounded patients into the military field hospital

Time (h)	Vietnam 1964-1973 (USA) %	Afghanistan 1979-1989 (USSR) %	North Caucasus 1994-1997 (Russia) %
< 1	-	22.9-58.7	-
1-2	95	25.9	8.4
2-4	-	9.1-21.5	7.6
4-8	5	6.8-73	24.8
8-12	-	4.9-10.6	46.9
12-24	-	2.1-16.1	6.2
> 24	-	0.7-32	6.1

Conditions and Equipment in Trauma Care

Applying the Advanced-Trauma-Life-Support (ATLS®) in trauma centers have improved the trauma care in the last decades, as Van Olden et al. demonstrated that introduction of the ATLS® program in trauma care had significantly improved the early outcomes, and identified a significantly lower numbers of patients with inadequate management [39, 40]. Moreover, CT scan use had improved the diagnosis ability, in which the availability of multi-sliced CT (MSCT) scan in emergency departments might help in improving the velocity [41, 42], and occupancy [41, 43-45]of the diagnostic procedures in the abdomen and pelvis injuries. In this context, MSCT was introduced in the primary survey of polytrauma victims [46-48], as Hilbert et al. observed a significant decrease in the mortality rates from 15 % to 8.6 % after integration of MSCT in to the Emergency Room [42].

Trauma triage starts as soon as emergency services, ambulance or paramedics arrive to the accident site. Emergency medical service (EMS) studies at the major road traffic accident in Switzerland (April 9, 2008) showed that emergency services were on the accident site after 15 minutes; all injured were evacuated to hospitals within 70-140 minutes [49],while analysis of German trauma registry data on the injured patients at the age of 18-50 years from January 1993 to December 2007 showed that the average time for patients delivery was about 71.7 min [50].Under civilian conditions, the mass delivery of wounded patients may be prevented through correct triaging as early as possible, which leads to provide the full surgical care to a greater number of the injured patients.

On other hand, in warfare settings, the medical service providers are in close contact with soldiers; they are trained as self- or “buddy” treatment skills. Patients flow directed to one field hospital accordingly the logic followed must be to “do the best for the most” and not “everything for everyone” (Table 2).  Moreover, there is a lack of medical institutions and specialists; “traumatic epidemics” arises. One of the major differences between military and civilian DCS approach, under field conditions the mass delivery of the wounded patients constitutes already the indication for using abbreviated surgery.

Table 2

Delivery time into the military field hospital, North Caucasus (Koltovich A., 2011). The average delivery time of wounded patients from the warfare site during counterterrorist operations in the North Caucasus (years 1994-1997, 1999-2006) to the echelon of rendering qualified medical care made up 82.3±28.5 minutes. The minimum delivery time was 15 minutes, while, the maximum 485 minutes

Time, h	%
< 1	33.2
1-2	46.4
2-3	11.5
3-6	7.6
> 6	1.3
Total	100

When comparing the DCS approach in warfare and civilian setting, the principles of such approach are similar. It consists of several stages, each stage being performed in strict sequence and according to indications. At rendering aid under field conditions, the number of echelons is much greater that at rendering aid in a traumatology center. If in the second case their number is from 3 to 5, then in the first one – up to 10 echelons, depending on the warfare site and location of hospitals that provide care (from medical companies to military field hospitals at warfare site to the main rear hospitals of the country; Table 3).

 Table 3

Damage control surgical approach in civilian and combat setting

CIVILIAN DAMAGE CONTROL	MILITARY DAMAGE CONTROL
Single institution	Multiple institution
Out of hospital care	Out of battle field hospital (BFH) care
Abbreviated operation	Abbreviated operation
	Resuscitation at a forward surgical facility
	Air evacuation by helicopter
ICU Resuscitation	Preoperative resuscitation at combat support hospital
	Definitive or second look abbreviated operation
	Postoperative Resuscitation
	Fixed-wing global Evacuation
Definitive operation	Definitive operation or ICU care
Reconstructive operation	Evacuation to the Trauma Center of the Country  for Reconstructive operation

CONCLUSION:

Damage control surgical approach is an important achievement in field of trauma surgery by civilian surgeons’, which also in use by military surgeons’ with regard to conditions they encounter during military actions. During operations, military surgeons use the same techniques of abbreviated operations as civilian surgeons do, and this is where the main similarity lies. While, the differences related to the characteristic of wounds, military conditions, isolated location, limitation in the resources and medical services, and necessity for compulsory evacuationto rear hospitals.