Backed Into a Corner: Damage Control Surgery in the Rural or Austere Setting

Educational Objectives

The goal of this program is to improve use of damage control surgery in rural hospitals. After hearing and assimilating this program, the clinician will be better able to:

1. Perform damage control surgery to maximize patient outcomes in rural community hospitals.

Summary

Introduction: the goal of damage control surgery (DCS) is to correct the “lethal triad” (ie, gain early control of bleeding and sepsis); in smaller facilities, DCS is essential because of delays in transport or lack of specialists; rural hospitals can provide temporizing measures similar to higher-level centers if plans for postprocedure disposition are in place

Necrotizing fasciitis: a 9-fold increase in mortality occurs with delay in care >24 hr; thus, debridement should be performed in a timely manner; lack of operating room (OR) availability, acute care service team, and plastic surgeon (for reconstruction) are all reasons for delay of care; a definitive plan to transfer the patient after debridement is essential, as necessary resources are not usually available at rural hospitals; consider utilizing safe-haven beds (unlicensed beds not counted in the daily census; staffed by nurses from the resource pool) or direct transfer to the postanesthesia care unit or to the OR to help prevent excessive (24-72 hr) delays in transfer

Pelvic hemorrhage: though surgeons may lack adequate familiarity with resuscitative endovascular balloon occlusion of the aorta, preperitoneal pelvic packing can be performed to manage a patient with hypotension secondary to a pelvic fracture when orthopedic trauma care, interventional radiology, or adequate blood are not available; advise surgeons to adequately review techniques through courses, videos, or books

Vascular injury requiring shunting: check availability of shunts, and confirm types, expiration dates, and appropriate use techniques; for level 3 or 4 trauma centers and critical access hospitals, a low threshold for fasciotomy is advisable if a 2- to 3-day delay in transfer is expected; consider using a small-bore chest tube, central line, or feeding tube if a true vascular shunt is not available; a designated person should contact surrounding facilities and arrange postsurgical transport

Emergency department thoracotomy: have a stocked mobile trauma cart readily available; plan ahead for return of circulation

Recommendations for damage control preparedness: have a working relationship with the receiving facility; have a transport plan; routinely check and restock supplies; encourage continuing education

Readings

Feliciano DV, Mattox KL, Jordan GL Jr. Intra-abdominal packing for control of hepatic hemorrhage: a reappraisal. J Trauma. 1981;21(4):285-290. doi:10.1097/00005373-198104000-00005; Roje Z, Roje Z, Matić D, et al. Necrotizing fasciitis: literature review of contemporary strategies for diagnosing and management with three case reports: torso, abdominal wall, upper and lower limbs. World J Emerg Surg. 2011;6(1):46. doi:10.1186/1749-7922-6-46; Turner J, Wilson A. Backed into a corner: damage control surgery in the rural or austere setting. Trauma Surg Acute Care Open. 2024;9(Suppl 2):e001391. doi:10.1136/tsaco-2024-001391.

Disclosures

For this program members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Turner was recorded at the Mattox Vegas Trauma, Critical Care and Acute Care Surgery 2024, held April 15-17, 2024, in Las Vegas, NV, and presented by Trauma and Critical Care Foundation. For information on upcoming CME activities from this presenter, please visit https://www.trauma-criticalcare.com. Audio Digest thanks the speakers and Trauma and Critical Care Foundation for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.50 CE contact hours.

Lecture ID:

GS711903

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.