Damage Control Resuscitation und Damage Control Surgery

Nach Abschluss des „Primary Survey“ eines Schwerverletzten muss im Schockraum eine kritische Behandlungsentscheidung getroffen werden: Eignet sich der Patient für eine frühe endgültige operative Versorgung („Early total Care“) seiner Verletzungen? Oder erscheint er zu instabil, sodass zunächst nur unmittelbar lebensrettende Eingriffe zur Blutungs- und Kontaminationskontrolle möglich sind („Damage Control Surgery“)?

Abstract

Trauma triggers complex physiological responses with primary and secondary effects vital to understanding and managing trauma impact. “Damage Control” (DC), a concept adapted from naval practices, refers to abbreviated initial surgical care focused on controlling bleeding and contamination, critical for the survival of severely compromised patients. This impacts anaesthesia procedures and intensive care. “Damage Control Resuscitation” (DCR) is an interdisciplinary approach aimed at reducing mortality in severely injured patients, despite potentially increasing morbidity and ICU duration. Current medical guidelines incorporate DC strategies.

DC is most beneficial for patients with severe physiological injury, where surgical trauma (“second hit”) poses greater risks than delayed treatment. Patient assessment for DC includes evaluating injury severity, physiological reserves, and anticipated surgical and treatment strain. Inadequate intervention can worsen trauma-induced complications like coagulopathy, acidosis, hypothermia, and hypocalcaemia.

DCR focuses on rapidly restoring homeostasis with minimal additional burden. It includes rapid haemostasis, controlled permissive hypotension, early blood transfusion, haemostasis optimization, and temperature normalization, tailored to individual patient needs.

“Damage Control Surgery” (DCS) involves phases like rapid haemostasis, contamination control, temporary wound closure, intensive stabilization, planned reoperations, and final wound closure. Each phase is crucial for managing severely injured patients, balancing immediate life-saving procedures and preparing for subsequent surgeries.

Intensive care post-DCS emphasizes stabilizing patients hemodynamically, metabolically, and coagulopathically while restoring normothermia. Decision-making in trauma care is complex, involving precise patient assessment, treatment prioritization, and team coordination. The potential of AI-based decision support systems is noted for their ability to analyse patient data in real-time, aiding in decision-making through evidence-based recommendations.

Kernaussagen

• Ziel von Damage-Control-Verfahren ist, das Überleben von schwerstverletzten Patienten zu ermöglichen, die sich bereits in einem ausgeprägten Schockzustand befinden. Diese Patienten besitzen keine physiologischen Reserven mehr, um zusätzliche Belastungen durch ausgedehnte operative Eingriffe zu kompensieren.

• Grundlage sind eine schnelle Blutungs- und Kontaminationskontrolle sowie eine abgekürzte chirurgische Versorgung mit temporärem Wundverschluss.

• Danach erfolgt eine weitere Stabilisierung auf der Intensivstation.

• Die Schocktherapie zielt auf die Vermeidung von Koagulopathie, Azidose, Hypothermie und Hypokalzämie ab.

• Besondere Bedeutung besitzen ein angepasster Volumenersatz und permissive Hypotension bis zur Blutungskontrolle unter Beachtung von Kontraindikationen (ZNS-Verletzung). Ebenso ein an der Vollblutzusammensetzung orientiertes Transfusionsregime (EK : FFP : TK = 4 : 4 : 1) sowie der zielgerichtete Einsatz von Gerinnungsprodukten.

• Folgeeingriffe finden erst nach physiologischer Stabilisierung statt.

Schlüsselwörter

Damage Control Resuscitation - Damage Control Surgery - Polytrauma - Schock - Intensivmedizin

Keywords

damage control resuscitation - damage control surgery - multiple trauma - shock - intensive care medicine

Publication History

Article published online:
24 June 2024

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