Clinical Application Study Of Damage Control Surgery For Severe Multiple Traumas

Background:The trauma impact itself determines primary organ or soft-tissue injuries and fractures (first hit, trauma load) with local tissue damages as well as a systemic inflammation with release of pro-inflammatory ("systemic inflammatory response syndrome" ) and anti-inflammatory("compensatory anti-inflammatory response syndrome" )cytokines, complement factors, proteins of the contact phase and coagulation systems, acute-phase proteins, neuroendocrine mediators, and an accumulation of immunocompetent cells at the local side of tissue damage (host defense response). The approach of " damage control" surgery takes the influence of systemic posttraumatic inflammatory and metabolic reactions of the organism into account and is aimed at reducing both the primary and the secondary-delayed-mortality in severely injured patients. The present paper shall provide an overview on the current state of management algorithms for polytrauma patients. Objective:1. To investigate the features of multiple traumas and its management.2. To explore the therapeutical effect of damage control surgery for multiple traumas.3. To conclude our experiences of diagnosising and treating multiple traumas patients. Methods:The clinical data of 322 patients with severe multiple traumas admitted from June 2001 to June 2007 were analyzed retrospectively. These severely injured patients with an ISS > 16 points were included in a retrospective analysis. Data collected for analysis consist of the general characteristic of the multiple traumas patients, mechanism and timing of injury, incidence of complications and mortality. Among these patients, 45 patients were classified to the DCS group, 45 patients to the ETC group. Between the two groups, the body temperature, PT and APTT recovery time, clearance time of lactic acid, incidences of complications, mortality, volume of bleeding and blood transfusion, operation time, duration of hospital and ICU stay were compared respectively. Results:1. 303(91%) of 322 patients were successfully treated and 19(5.9%) patients were dead. Complications occurred in 54 (16.8%)cases. The incidences of adult respiratory distress syndrome, diffuse intravascular coagulation, multiple organs dys- function syndrome, abdominal compartment syndrome and infection were 5% (16 / 322), 2.5% (8 / 322), 2.8% (9 / 322), 1%(3 / 322), 5% (16 / 322), respectively. 2. The damage control surgery was successfully performed in 42(93.3%) of 45 patients. All cases received discriminating internal fixation after resuscitation in ICU. Of 3 died patients, 1 patients died in 24 hours,. with average injury severity score(ISS) of 45. The incidences of adult respiratory distress syndrome, diffuse intravascular coagulation, multiple organs dysfunction syndrome and infection were 6.7% (3 / 45), 4.4% (2 / 45), 2.2%(1 / 45), 6.7% (3 / 45),respectively. 37 (82.2%)of 45 patients survived in the early total care (ETC) group. Of 8 died patients, 5 patients died in 24 hours. The overall mortality rate Was 17.8%(8/45), with average injury severity score(ISS) of 40.6 and shock and combined injuries as the main causes of death. The incidences of adult respiratory distress syndrome, diffuse intravascular coagulation, multiple organs dysfunction syndrome, abdominal compartment syndrome and infection were 13.3%(6 / 45), 8.9% (4 / 45), 6.7%(3 / 45), 22.2% (2 / 45), 13.3% (6 / 45), respectively.3. The recovery time of body temperature, PT, APTT and clearance time of lactic acid in damage control group were shorter than these in early total care group. Incidence of complications and mortality in damage control group were less than these in the other group. There were significant differences in two groups(P<0.05). The mean duration of hospital stay were 27.5±8.5 days in DCS group, of which were longer than 21.4±7.8 days in ETC group. The ICU days were 10.25±5.61 days in DCS group, of which were longer than 8.32±4.93 days in ETC group, too. There were significant difference in two groups (P <0.05).4. No significant differences existed in the volume of bleeding and blood transfusion between two groups(P>0.05).Conclusions:1. Multiple traumas was imbued with epidemiological regularity and characteristic clinical course in its occurrence and development.2. A combined continuous work procedures of pre-hospital emergency treatment, hospital treatment, rehabilitation could improve the level of multiple injuries treatment, reduce mortality and the incidence of complications;3. The concept of DCS could reduce multiple traumas patients' mortality rate and incidence of complications.4. The concept of DCS was well established for the management of thoracic, abdominal, vascular, pelvic, extremity and soft-tissue injuries in severely injured patients. Multiple traumas should be considered as a systemic surgical disease. The cognition of pathology, physiology, anabiosis, accurate injury classification and elaborative therapeutic plan was the key of successful treatment. In order to save the lives of multiple traumas patients and improve the physiological state, the damage control surgery should be considered first.