Perioperative & Surgical Care

Damage control surgery: principles

Clinical Overview and When to Suspect Need for Damage Control Surgery

— Stage 1 (Operating room): rapid hemorrhage and contamination control, temporary abdominal closure

— Stage 2 (ICU): rewarming, correction of coagulopathy and acidosis, resuscitation

— Stage 3 (Return to OR): definitive repair, anastomoses, fascial closure

— Hypothermia <35°C (often <34°C)

— Acidosis pH <7.2 or base deficit >8–10

— Coagulopathy INR >1.5, clinical nonsurgical bleeding

— Massive transfusion (>10 units PRBC in 24 h or activation of MTP)

— Persistent hypotension (SBP <90) despite resuscitation

— Inability to achieve hemostasis with conventional technique

— Penetrating abdominal trauma with multiple visceral or vascular injuries

— Blunt trauma with hepatic, splenic, or major vascular disruption

— Ruptured AAA with profound shock

— Mesenteric ischemia with bowel of questionable viability

— Severe necrotizing pancreatitis or postoperative intra-abdominal catastrophe with septic shock

Damage control surgery (DCS) is a staged operative strategy for the exsanguinating, physiologically devastated patient in whom completing a definitive repair would be lethal.

Core philosophy: abbreviate the index operation, restore physiology in the ICU, then return for definitive repair — typically within 24–48 hours.

Three classic stages:

When to suspect DCS is needed (the "lethal triad" plus physiology):

Common clinical scenarios:

Board pearl: The decision to "bail out" with damage control is made before the patient is moribund — anticipating the lethal triad, not chasing it. Once pH <7.2 and core temp <34°C set in, mortality climbs steeply regardless of subsequent care.

Step 3 framing: DCS is a strategy, not a single operation. On CCS-style cases, the correct move is often "control hemorrhage, pack, temporary closure, ICU" rather than a single-stage definitive repair in a crashing patient.

Presentation Patterns and Key History

— Penetrating torso injury with hypotension on arrival, FAST positive, transfusion already initiated en route

— Blunt polytrauma with pelvic fracture, hemoperitoneum, long-bone fractures

— Mechanism of high energy: MVC at highway speed, fall >20 ft, GSW to torso

— Ruptured AAA: abrupt back/flank pain, syncope, pulsatile mass

— Mesenteric ischemia: "pain out of proportion," AFib, lactic acidosis

— Perforated viscus with feculent peritonitis and septic shock

— POD#1–3 after vascular or GI surgery with rising lactate, falling Hgb, abdominal distension, vasopressor escalation

— AMPLE: Allergies, Medications (anticoagulants!), Past history, Last meal, Events

— Anticoagulant/antiplatelet use — apixaban, warfarin, clopidogrel dramatically change reversal strategy

— Cirrhosis, ESRD, prior abdominal surgery (adhesions), known aneurysm

— Time of injury or symptom onset (warm/cold ischemia clock for bowel and limbs)

— Prehospital SBP <90, prehospital transfusion, prolonged extrication

— Shock index (HR/SBP) >1.0

— Need for tourniquet, REBOA, or pelvic binder en route

Patients arrive through one of three doors: trauma bay, emergency laparotomy, or postoperative deterioration.

Trauma presentation:

Nontrauma emergency presentation:

Postoperative decompensation:

Key history to obtain rapidly (often parallel to resuscitation):

Pre-arrival data that should trigger DCS thinking:

Key distinction: A hemodynamically normal penetrating abdominal trauma patient gets a careful definitive laparotomy; the persistently hypotensive, coagulopathic, hypothermic patient gets damage control. The history that flags DCS is physiology that fails to respond to resuscitation, not the injury pattern alone.

Step 3 management: While history is being gathered, activate the massive transfusion protocol (MTP) at 1:1:1 ratio (PRBC:FFP:platelets), send type-and-crossmatch, TEG/ROTEM if available, and notify OR and blood bank simultaneously — don't sequence these tasks.

Physical Exam Findings and Hemodynamic Assessment

— Often intubated for shock or GCS <8

— Asymmetric breath sounds → tension pneumothorax or hemothorax (decompress before laparotomy)

— Class III–IV hemorrhagic shock: HR >120, SBP <90, narrow pulse pressure, mottled cool extremities, capillary refill >3 sec, altered mentation

— Shock index (HR/SBP) >1.0 = significant hemorrhage; >1.4 = massive transfusion likely

— Distended, rigid abdomen; positive FAST; pelvic instability

— Active external bleeding requiring tourniquet or pressure

— Agitation or obtundation from cerebral hypoperfusion (not just TBI)

— Hypothermia is exam-detected: cool trunk, no shivering (shivering stops <32°C)

— Log-roll: posterior wounds, flank ecchymosis (Grey-Turner), perineal injury

— Core temp <35°C

— pH <7.2, base deficit >8

— Diffuse oozing from cut surfaces, suture lines, raw peritoneum (clinical coagulopathy)

— Transfusion >10 units PRBC

— Operative time approaching 90 min in unstable patient

— Need for vasopressors to maintain MAP >65

Primary survey (ABCDE) drives early findings — DCS candidates fail "C" repeatedly.

Airway/Breathing:

Circulation — the cardinal exam:

Disability:

Exposure:

Intraoperative physiologic markers that trigger conversion to DCS:

CCS pearl: In the simulated case, vital signs that trend the wrong way despite resuscitation are the trigger — order serial ABGs, lactate q1–2h, core temp, and coag panels. The pattern "rising lactate, falling pH, dropping temp" = abort definitive repair, pack and close temporarily.

Board pearl: The lethal triad (hypothermia, acidosis, coagulopathy) is self-reinforcing: hypothermia worsens platelet function and clotting cascade enzymatic activity; acidosis impairs thrombin generation; coagulopathy drives further bleeding and hypothermia. Breaking the cycle requires leaving the OR, not staying longer.

Diagnostic Workup — Initial Labs and Imaging

— Type and crossmatch (priority — uncrossmatched O-neg if needed)

— CBC (baseline Hgb often normal in acute hemorrhage — don't be falsely reassured)

— Lactate and base deficit — best surrogates for tissue hypoperfusion

— ABG including pH

— Coagulation: PT/INR, aPTT, fibrinogen, platelets

— TEG or ROTEM — guides goal-directed component therapy (low MA → platelets; low alpha angle → fibrinogen/cryo; prolonged R → FFP; lysis → TXA)

— BMP, calcium (ionized — drops with citrate from transfusions)

— Beta-hCG in women of reproductive age

— Toxicology, ethanol if indicated

— FAST exam at bedside — fluid in Morison's pouch, splenorenal, pelvis, pericardium

— Chest and pelvic X-ray (the trauma "trinity" with FAST)

— Positive FAST + hemodynamic instability = OR, not CT

— Pan-scan CT with IV contrast (CTA chest/abdomen/pelvis) for blunt polytrauma

— CTA for vascular blush, active extravasation → consider IR embolization adjunct

— pH, lactate, ionized Ca, K, Hgb, fibrinogen, temp

Labs are drawn at IV placement and resuscitation runs in parallel — do not delay OR for results in the crashing patient.

Core trauma/DCS labs:

Imaging in the unstable patient:

Imaging in the stabilized or borderline patient:

Pre-induction "panic labs" repeated q30–60 min intraoperatively:

Step 3 management: Tranexamic acid (TXA) 1 g IV within 3 hours of injury in bleeding trauma patients, followed by 1 g over 8 hours. After 3 hours, TXA may increase mortality — timing matters.

Board pearl: A normal initial Hgb does not rule out major hemorrhage. Base deficit and lactate are far more sensitive for occult shock; a base deficit >6 in trauma predicts increased transfusion requirement and mortality.

Avoid sending labs that delay disposition — the unstable FAST-positive patient goes to OR with labs pending.

Diagnostic Workup — Advanced and Confirmatory Studies

— Identifies solid organ injury grades (AAST), vascular blush, retroperitoneal hematoma, bowel injury (free air, mesenteric stranding)

— Guides selective nonoperative management vs. IR embolization vs. operative intervention

— Splenic artery embolization for high-grade splenic injury with blush

— Hepatic artery embolization adjunct to perihepatic packing in DCS

— Pelvic angioembolization for arterial pelvic bleeding after binder placement

— Often performed between damage control stages or as a hybrid OR procedure

— Zone 1 (supraceliac) for abdominal/pelvic exsanguination

— Zone 3 (infrarenal) for pelvic/junctional hemorrhage

— Temporizing only — must be followed by definitive control within 30–60 minutes

— TEE/TTE for suspected cardiac injury, tamponade, or unexplained shock

— Identifies missed injuries, ongoing bleeding, abscess formation, ischemic bowel before stage 3 takeback

Advanced studies are reserved for the transient responder or responder — the nonresponder goes directly to OR.

CT angiography (CTA) of chest/abdomen/pelvis:

Catheter angiography with embolization (interventional radiology):

REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta):

Echocardiography:

Bronchoscopy/esophagoscopy for selective penetrating neck or transmediastinal injuries when stable

Repeat TEG/ROTEM to guide ongoing component therapy in ICU between stages

CT after stage 1 DCS (the "open abdomen CT"):

Key distinction: Stable patient + positive FAST → CT to characterize; unstable patient + positive FAST → straight to OR. CT is the enemy of the exsanguinating patient — the "doughnut of death."

Board pearl: Diagnostic peritoneal aspiration/lavage (DPL/DPA) is rarely used today but remains the answer when FAST is equivocal in an unstable blunt trauma patient and CT is not feasible — grossly bloody aspirate (>10 mL) mandates laparotomy.

Risk Stratification and Decision Logic for Damage Control

— Temperature <35°C (especially <34°C)

— pH <7.2 or base deficit >8

— Coagulopathy: INR >1.5, clinically diffuse oozing

— Transfusion >10 units PRBC or anticipated massive transfusion

— Operative time >90 min in unstable patient

— Inability to achieve hemostasis conventionally

— Inability to close abdomen without tension (visceral edema, packing in place)

— Need to reassess questionable bowel viability

— Penetrating torso injury with SBP <90

— Need for prehospital intubation + transfusion

— Pelvic fracture with hemodynamic instability

— Major vascular injury suspected

— Definitive repair in stable patient: lower morbidity, single anesthetic

— DCS in unstable patient: higher cumulative morbidity (open abdomen complications) but dramatically lower mortality compared to attempted definitive repair

— Stable patient — DCS adds unnecessary morbidity (enterocutaneous fistula, ventral hernia, prolonged ICU stay)

— Isolated injuries amenable to quick definitive repair

Decision to pursue DCS rests on physiologic rather than anatomic criteria.

Indications for damage control laparotomy (any of):

Pre-operative predictors (consider DCS before incision):

Risk-benefit framing:

Contraindications/cautions:

Step 3 management: The decision tree at laparotomy: (1) Control hemorrhage (clamp, ligate, shunt, pack); (2) Control contamination (staple off bowel, no anastomosis); (3) Temporary abdominal closure (vac dressing, Bogota bag, towel clip); (4) ICU resuscitation; (5) Planned reoperation in 24–48 h.

Board pearl: Vascular shunts (Argyle, Pruitt-Inahara, or even sterile IV tubing) are the damage control answer for major arterial injuries that can't be definitively repaired in the unstable patient — restore distal flow, return later for definitive bypass. Limb salvage clock starts at 6 hours warm ischemia.

Pharmacotherapy — Resuscitation and Hemostatic Agents

— PRBC, FFP, platelets in equal ratios

— Whole blood (cold-stored low-titer O) where available — increasingly preferred

— Cryoprecipitate when fibrinogen <150–200 mg/dL

— Goal: fibrinogen >150–200, platelets >50–100k, INR <1.5

— 1 g IV over 10 min within 3 hours of injury, then 1 g over 8 h

— CRASH-2/MATTERs data; antifibrinolytic, reduces all-cause mortality

— After 3 hours, TXA may increase mortality — do not give late

— Citrate from massive transfusion chelates ionized calcium

— Replace with CaCl₂ 1 g IV after every 4 units PRBC or per ionized Ca

— Hypocalcemia worsens coagulopathy and cardiac contractility ("Diamond of Death" = lethal triad + hypocalcemia)

— Avoid as primary therapy — vasoconstriction in hypovolemia worsens tissue hypoperfusion

— Norepinephrine acceptable bridge after volume to maintain MAP ≥65 mmHg

— Warfarin → 4-factor PCC (preferred over FFP for speed) + vitamin K 10 mg IV

— Dabigatran → idarucizumab 5 g IV

— Apixaban/rivaroxaban → andexanet alfa or 4-factor PCC

— Heparin → protamine

— Antiplatelets → platelet transfusion (controversial in TBI without surgery)

— Target SBP 80–90 mmHg in penetrating trauma without TBI

— In TBI: maintain SBP ≥110 (cerebral perfusion)

DCS pharmacology centers on hemostatic resuscitation — replace what's lost, restore physiology, avoid crystalloid-driven coagulopathy.

Blood products (MTP 1:1:1):

Tranexamic acid (TXA):

Calcium:

Vasopressors:

Reversal agents (anticoagulated patients):

Permissive hypotension (until hemorrhage controlled):

Avoid crystalloid overload — dilutes clotting factors, worsens edema, hyperchloremic acidosis with NS

Board pearl: Damage control resuscitation = permissive hypotension + hemostatic resuscitation (1:1:1) + minimal crystalloid + early TXA + warming. These principles begin prehospital and continue through stage 2 ICU phase.

Operative and Procedural Management — The Three Stages

— Hemorrhage control first: four-quadrant packing on entry, then systematic exploration

— Solid organ: pack the liver (perihepatic packing), splenectomy for spleen, nephrectomy if contralateral kidney functional

— Major vascular: ligate expendable vessels (IIA, single iliac vein), shunt non-expendable (SMA, common iliac artery, popliteal)

— Contamination control: staple off bowel injuries with GIA stapler, no anastomoses, no stomas

— Bladder/ureter: tube drainage, defer reconstruction

— Pancreas: wide drainage, no Whipple

— Temporary abdominal closure: negative-pressure wound therapy (ABThera), Bogota bag, or towel clip closure — fascia left open

— Rewarm to >36°C (warm fluids, Bair Hugger, warm room)

— Correct acidosis (perfusion, not bicarb)

— Correct coagulopathy (products, TEG-guided)

— Mechanical ventilation, sedation, monitor for abdominal compartment syndrome (bladder pressure >20 mmHg + organ dysfunction)

— Antibiotics if hollow viscus injury

— IR embolization adjunct if ongoing bleeding (e.g., pelvic, hepatic)

— Remove packs, reassess injuries

— Bowel anastomoses or stoma creation

— Definitive vascular repair (replace shunts with bypass/graft)

— Attempt primary fascial closure; if not feasible, sequential closure with vac, mesh-mediated traction, or planned ventral hernia with skin graft over granulating viscera

Stage 1 — Index operation (≤60–90 min):

Stage 2 — ICU resuscitation (24–48 h):

Stage 3 — Definitive repair (24–48 h post-index):

Damage control orthopedics: external fixation of long bones/pelvis in stage 1; convert to internal fixation when physiology permits.

Damage control thoracotomy: ED resuscitative thoracotomy for penetrating chest with witnessed loss of vitals — cross-clamp aorta, relieve tamponade, control hilum.

CCS pearl: Order set after stage 1: ICU admit, ventilator, warming, q1h vitals, q2h ABG/lactate/CBC/coags/iCal, MTP continuation per TEG, antibiotics, sedation, DVT prophylaxis once bleeding controlled, plan return to OR in 24–48 h.

Special Populations — Elderly and Renal/Hepatic Impairment

— Diminished physiologic reserve — develop the lethal triad faster and at less severe injury

— Often on anticoagulants (warfarin, DOACs) and antiplatelets — early reversal critical

— Beta-blockers blunt tachycardic response → shock index may be falsely reassuring; rely on lactate, base deficit, mentation

— Lower threshold for MTP activation and DCS

— Higher mortality at every injury severity score; goals-of-care discussion important early with family

— Baseline uremic platelet dysfunction → DDAVP 0.3 mcg/kg IV improves platelet function

— Avoid contrast nephropathy if possible; if CTA needed, give it (life > kidney)

— Heparin reversal: protamine; dialysis can clear dabigatran

— Adjust postoperative antibiotic doses; avoid nephrotoxins (aminoglycosides, NSAIDs)

— Volume management — anuric patients tolerate less crystalloid; consider early CRRT in ICU phase

— Baseline coagulopathy (decreased factor synthesis) and thrombocytopenia (splenic sequestration)

— INR does not reliably reflect bleeding risk — use TEG/ROTEM and clinical bleeding

— Higher transfusion requirements; expect refractory coagulopathy

— Increased risk of postoperative liver failure and ascites leak from open abdomen

— MELD score predicts mortality; MELD >20 in emergency laparotomy carries ~50% mortality

— Clinical Frailty Scale ≥5 predicts poor outcomes after major emergency surgery

— Integrate into goals-of-care conversation

Elderly (>65):

Renal impairment / ESRD:

Hepatic impairment / cirrhosis:

Frailty:

Step 3 management: In the elderly anticoagulated trauma patient with intracranial or intra-abdominal hemorrhage, reverse first, image second, operate third — order 4-factor PCC for warfarin (25–50 units/kg) + vitamin K 10 mg IV, or andexanet/PCC for Xa inhibitors, simultaneously with trauma activation. Do not wait for imaging.

Board pearl: In cirrhotic trauma patients, the open abdomen leaks massive ascites — high-output protein loss, electrolyte derangement, and difficult fascial closure. Anticipate albumin replacement and early TIPS evaluation if portal hypertension drives bleeding.

Special Populations — Pregnancy and Pediatrics

— Trauma is leading nonobstetric cause of maternal death

— Physiologic changes: blood volume +40%, HR +15–20, mild respiratory alkalosis, relative anemia — mother compensates and maintains BP at the fetus's expense

— Fetal distress may be the first sign of maternal shock

— Left lateral tilt (15°) or manual uterine displacement to relieve IVC compression after 20 weeks

— Rh-negative mother → anti-D immunoglobulin (RhoGAM) within 72 h; Kleihauer-Betke to quantify fetomaternal hemorrhage

— Continuous fetal monitoring for ≥4 h (≥24 h if abnormal) after 20–24 weeks

— Perimortem cesarean within 4 minutes of maternal arrest at ≥20–24 weeks gestation — improves both maternal and fetal outcome

— DCS principles apply identically; do not withhold imaging, TXA, or operation for pregnancy

— Larger head, more abdominal organ exposure, compliant chest wall (internal injury without rib fracture)

— Maintain normotension (no permissive hypotension in children) — hypotension is a late, ominous sign; children compensate via tachycardia

— Weight-based resuscitation: 20 mL/kg crystalloid bolus, then 10–20 mL/kg PRBC if persistent shock

— Higher rate of nonoperative management for solid organ injury (spleen, liver) — but DCS principles still apply when unstable

— TXA dosing: 15 mg/kg (max 1 g) loading

— Hypothermia develops faster (high surface-area-to-mass ratio) — aggressive warming

— Broselow tape for equipment and drug dosing

Pregnant trauma patient:

Pediatric patient:

Key distinction: Pediatric splenic injury — nonoperative management is the default for hemodynamically stable patients regardless of grade. DCS/splenectomy only for hemodynamic failure. Adults follow similar but slightly more liberal operative thresholds.

Board pearl: In a pregnant trauma patient, the best resuscitation for the fetus is aggressive resuscitation of the mother. Order maternal labs, FAST, CT as indicated, MTP if needed, and obstetric consult — but do not delay damage control for fetal considerations.

Complications and Adverse Outcomes

— Sustained intra-abdominal pressure >20 mmHg + new organ dysfunction

— Measured via bladder pressure transduction

— Manifestations: oliguria, peak airway pressures rising, hypotension, lactic acidosis, distended abdomen

— Treatment: decompressive laparotomy — emergent return to OR; medical measures (sedation, paralysis, NG decompression, diuresis) are temporizing only

— Prevention is the indication for open abdomen in DCS

— 5–25% with open abdomen; higher with prolonged open status

— Catastrophic when bowel exposed in granulating wound bed ("enteroatmospheric")

— Management: nutritional support (often TPN), wound care, delayed reconstruction

— From spillage, anastomotic leak, devitalized tissue

— Treat with source control (percutaneous drain or operative) + antibiotics

— Inevitable if fascia not closed; planned ventral hernia with skin graft → staged repair at 6–12 months with component separation or mesh

— May require return to OR, IR embolization, factor VIIa as last resort

— From shock, rhabdomyolysis, contrast, abdominal hypertension — may require CRRT

— High risk after major trauma; start chemical prophylaxis (LMWH) within 24–48 h once bleeding controlled — do not delay indefinitely

— Open abdomen loses ~2 g nitrogen per liter of effluent — high protein needs (2–2.5 g/kg/day)

— PTSD, chronic pain, hernias, body image, return-to-work delays

Abdominal compartment syndrome (ACS):

Enterocutaneous/enteroatmospheric fistula:

Intra-abdominal abscess and sepsis:

Ventral hernia:

Coagulopathy and persistent bleeding:

AKI:

VTE:

Surgical site infection and wound dehiscence

Nutritional deficits:

Long-term:

CCS pearl: New oliguria + rising peak airway pressures + distended abdomen in your post-DCS ICU patient → measure bladder pressure now. If >20 with organ dysfunction → call OR for decompressive laparotomy. Don't reach for more diuretics.

When to Escalate Care — ICU, Consult, and Inpatient Triage

— Mechanical ventilation, sedation, often paralysis

— Arterial line, central venous access, possible PA catheter in shock

— Continuous core temperature monitoring

— q1–2h ABG, lactate, CBC, coags, ionized calcium during active resuscitation

— Bladder pressure monitoring q4–6h while abdomen open

— CRRT capability for AKI

— Trauma surgery — primary

— Vascular surgery — for definitive vascular reconstruction

— Interventional radiology — embolization adjunct

— Orthopedics — pelvic and long-bone fixation

— Neurosurgery — concomitant TBI

— Cardiothoracic — thoracic injuries

— OB/GYN — pregnant patients

— Critical care/anesthesia — ICU comanagement

— Nutrition — early enteral or parenteral support

— Wound/ostomy nurse — open abdomen and stoma care

— Palliative care/social work — family communication

— Level I/II trauma center for definitive care

— Tube thoracostomy, intubation, MTP, and hemorrhage control before transfer

— Do not delay transfer for imaging at a lower-level facility ("scoop and run" for the exsanguinating patient)

— Early family meeting after stage 1 — discuss prognosis, expected course, possibility of withdrawal if futility emerges

— Identify surrogate decision-maker per state hierarchy

All DCS patients go to ICU between stages — this is not optional.

ICU admission needs:

Multidisciplinary consults:

Transfer considerations:

Step 3 management: Inter-hospital transfer of the DCS patient — call the receiving trauma surgeon directly, send all imaging on CD or via PACS network, send blood products with patient if available, accompany with critical care transport. Use EMTALA-compliant transfer with physician-to-physician handoff documented.

Goals-of-care escalation:

Board pearl: A patient who fails to clear lactate (target <2, or 50% reduction in 6 h) despite stage 2 resuscitation has ongoing bleeding or ischemic tissue — return to OR earlier, do not wait the full 48 hours.

Key Differentials — Other Causes of Refractory Shock in the Trauma/Surgical Patient

— External (scalp lacs in elderly, open fractures, scene blood loss)

— Chest (hemothorax — CXR, tube thoracostomy)

— Abdomen (FAST, CT, laparotomy)

— Pelvis/retroperitoneum (pelvic XR, CT, binder, angio)

— Long bones (especially femur — can lose 1–2 L per femur)

— Anastomotic bleeding post-GI surgery

— Solid organ rebleed after initial nonoperative management

— Vascular graft disruption or anastomotic pseudoaneurysm

— Retroperitoneal hematoma from access site (femoral catheterization)

— Surgical = focal, pulsatile, identifiable source → operation/IR

— Coagulopathic = diffuse, oozing from all raw surfaces → products, TEG-guided correction, warmth

— In reality both coexist in DCS patients — address both simultaneously

— TIC: immediate, driven by tissue injury and shock — protein C activation, hyperfibrinolysis

— DIC: later, consumptive, often septic

Within the hemorrhagic shock category, consider sources before assuming the "obvious" injury:

Five places blood hides (the trauma mantra):

Occult sources in surgical patients:

Coagulopathic vs surgical bleeding:

Trauma-induced coagulopathy (TIC) vs DIC:

Key distinction: Surgical bleeding does not stop with products. If your patient continues to bleed despite correcting coags and TEG normalizing, there is an anatomic source — return to OR or IR. Conversely, diffuse oozing in a normothermic patient with normal coags suggests retained surgical source.

Board pearl: Femur fracture in a hypotensive patient with negative FAST and no chest/pelvic source — the femur is your culprit. Apply traction splint, type-and-cross, and definitive fixation. Bilateral femurs can produce class III shock independently.

Key Differentials — Non-Hemorrhagic Shock in the Surgical Patient

— Tension pneumothorax — absent breath sounds, tracheal deviation, JVD → immediate needle/finger decompression then tube

— Cardiac tamponade — Beck's triad, FAST subxiphoid view, JVD with hypotension → pericardiocentesis or pericardial window

— Pulmonary embolism — postoperative day 3–10, sudden hypoxia and shock → CTA if stable, empiric anticoagulation or thrombolysis

— Blunt cardiac injury, MI triggered by stress of trauma/surgery

— ECG, troponin, echo

— Spinal cord injury above T6 — hypotension with bradycardia (vs hemorrhage tachycardia), warm dry skin

— Treat with fluids, vasopressors (norepinephrine), atropine for bradycardia

— Do not assume neurogenic — rule out hemorrhage first

— Postoperative day 3+ with fever, leukocytosis, hypotension responsive to fluid then needing pressors

— Source: anastomotic leak, missed bowel injury, pneumonia, line, urine

— Lactate, blood cultures, broad-spectrum antibiotics within 1 hour, source control

— Chronic steroid users with stress of surgery → stress-dose hydrocortisone

Not all shock in the trauma/postop patient is hemorrhagic — missing this changes management entirely.

Obstructive shock:

Cardiogenic shock:

Neurogenic shock:

Septic shock:

Anaphylaxis (latex, drugs, contrast) — wheezing, urticaria, hypotension → epinephrine IM

Adrenal insufficiency:

Air embolism, fat embolism (long-bone fractures 24–72 h, petechiae, hypoxia, neuro changes)

Step 3 management: Postop day 5 patient with hypotension, fever, tachycardia, leukocytosis, and abdominal pain → CT with contrast looking for anastomotic leak or intra-abdominal abscess; start broad-spectrum antibiotics (piperacillin-tazobactam or carbapenem) empirically while imaging; arrange source control (percutaneous drainage vs return to OR).

Board pearl: Hypotension + bradycardia in trauma = think neurogenic shock or vagal response (pericardial tamponade, abdominal hemorrhage with vagal stimulation) — not pure hemorrhage, which causes tachycardia.

Secondary Prevention, Discharge Medications, and Long-Term Plan

— Open abdomen that achieved primary fascial closure → standard wound care, monitor for SSI

— Planned ventral hernia with skin graft → abdominal binder, definitive repair at 6–12 months (component separation or mesh)

— Stoma patients → ostomy education, plan for reversal at 3–6 months if feasible

— LMWH (enoxaparin 30 mg BID or 40 mg daily) once bleeding risk acceptable

— Mechanical prophylaxis (SCDs) throughout

— Duration: at least until ambulatory; longer (4 weeks) for major abdominal/pelvic surgery, cancer, or persistent immobility

— Consider IVC filter only for documented VTE with absolute anticoagulation contraindication (not prophylactic)

— Continue high-protein diet (1.5–2 g/kg) until wound healing complete

— Consider tube feeds or supplements if oral intake inadequate

— Pneumococcal (PCV20 or PCV15+PPSV23), meningococcal (MenACWY + MenB), Hib, annual influenza

— Ideally 14 days post-splenectomy; if emergency, give before discharge

— Counsel on OPSI risk — fever → urgent evaluation, consider standby amoxicillin

— Restart cautiously after major bleeding event — multidisciplinary discussion balancing thrombotic vs rebleeding risk

— Screen for PTSD, depression at follow-up — high prevalence after major trauma/ICU stay

— Refer to psychology/psychiatry

— Seatbelt, helmet, firearm safety, substance use treatment if applicable

— Older adults: fall prevention, home safety assessment, medication review (especially anticoagulants)

After successful DCS and definitive closure, focus shifts to recovery, rehabilitation, and prevention of recurrence/complications.

Wound and abdominal wall:

VTE prophylaxis:

Nutrition:

Vaccination after splenectomy:

Anticoagulation resumption:

Mental health:

Injury prevention counseling:

Board pearl: Post-splenectomy sepsis (OPSI) has 50% mortality. Encapsulated organisms (S. pneumoniae, H. influenzae, N. meningitidis) are the culprits. Lifetime risk — vaccinate, educate, low threshold to treat fever as bacteremia.

Follow-Up, Monitoring, and Rehabilitation

— Daily wound checks, vital signs, I/Os, drain output

— Labs: CBC, BMP, LFTs, coags, nutrition markers (prealbumin, albumin)

— Imaging if concern for collection, leak, or ongoing process — CT with contrast

— Advance diet as tolerated; ostomy training; physical therapy mobilization

— Hemodynamically stable, off vasopressors

— Tolerating diet or stable tube feeds

— Adequate pain control on oral regimen

— Wound stable, drains managed

— Ambulating with PT clearance

— Social support and follow-up arranged

— Trauma/surgery clinic at 1–2 weeks for wound check, staple/suture removal

— 4–6 weeks for activity progression, imaging if indicated

— 3 months for planning definitive hernia repair or stoma reversal

— 6–12 months for hernia repair or final reconstruction

— Subspecialty follow-up (vascular, ortho, neurosurg) as indicated

— Inpatient rehab or skilled nursing for deconditioned/elderly patients

— Outpatient PT for strength and mobility — typically 6–12 weeks

— Avoid heavy lifting (>10 lb) for 6–8 weeks after laparotomy

— Return to work timing variable — sedentary 4–6 weeks, manual labor 8–12 weeks

— Fever, increasing pain, wound drainage, dehiscence → call surgeon

— Stoma output (high output >1.5 L/day) → dehydration risk

— Symptoms of incisional hernia (bulge, pain with strain)

— Smoking cessation — critical for wound healing and hernia repair success

— Alcohol/substance counseling if implicated in injury

Inpatient post-stage-3 monitoring:

Discharge criteria:

Outpatient follow-up cadence:

Rehabilitation:

Monitoring parameters at home:

Counseling:

Step 3 management: A discharged DCS patient with new fever, worsening abdominal pain, and tachycardia at 2 weeks → ED evaluation with CT abdomen/pelvis to rule out abscess, anastomotic leak, or fistula. Do not manage by phone with oral antibiotics.

CCS pearl: Order PT/OT consults, social work, nutrition, and outpatient trauma clinic follow-up before discharge — these are commonly missed steps that prevent readmission.

Ethical, Legal, and Patient Safety Considerations

— True informed consent often impossible — operate under implied/emergency consent doctrine when life-threatening emergency, patient incapacitated, and no surrogate immediately available

— Document the emergency and impossibility of obtaining consent

— Notify family as soon as feasible; obtain consent for subsequent stages when possible

— State hierarchy typically: spouse → adult children → parents → siblings

— Two-physician consent acceptable in emergencies in many jurisdictions

— Document attempts to reach next of kin

— DCS in a 90-year-old with multiple comorbidities and mangled extremity — discuss realistic outcomes with family

— Withdrawal of life-sustaining therapy discussions appropriate when persistent multiorgan failure, refractory shock, or devastating brain injury emerges

— Involve palliative care early — not just at end of life

— Gunshot wounds and stab wounds — most US states require law enforcement notification

— Suspected child abuse, elder abuse, intimate partner violence — mandatory reporting per state law; document objectively

— Motor vehicle crashes with intoxication may require reporting depending on jurisdiction

— Preserve clothing, document wound characteristics (do not call entrance/exit wounds without forensic training), bag hands of homicide victims, chain of custody for bullets/foreign bodies

— Retained surgical items — open abdomen with packs is high-risk; rigorous count discrepancy resolution at each takeback; intraoperative radiograph if count off

— Wrong-site/side surgery — time-out before every operation including takeback

— Handoff communication — SBAR or I-PASS at every transition (OR → ICU, shift change); residency duty-hour transitions are vulnerability points

— Most errors occur at handoff between trauma bay, OR, ICU, floor, rehab, and outpatient. Closed-loop communication and structured handoff tools reduce error.

Informed consent in the exsanguinating patient:

Surrogate decision-making:

Goals of care and futility:

Mandatory reporting:

Forensic considerations:

Patient safety in DCS:

Transition-of-care risk:

Board pearl: A trauma patient with a gunshot wound requires both medical care and notification of law enforcement per state statute — these are not in conflict; physician-patient confidentiality does not override mandatory reporting. Document objectively without speculation.

High-Yield Associations and Rapid-Fire Clinical Facts

Lethal triad = hypothermia (<35°C) + acidosis (pH <7.2) + coagulopathy (INR >1.5)

Add hypocalcemia → "Diamond of Death"

MTP ratio = 1:1:1 (PRBC:FFP:platelets) — mimics whole blood

TXA = 1 g IV within 3 hours of injury, then 1 g over 8 h

Permissive hypotension target = SBP 80–90 in penetrating trauma without TBI; in TBI keep SBP ≥110

Shock index >1.0 predicts MTP need

FAST exam views: pericardial (subxiphoid), perihepatic (Morison's), perisplenic, pelvic (Douglas)

Positive FAST + unstable = OR; positive FAST + stable = CT

Five places blood hides: external, chest, abdomen, pelvis/retroperitoneum, long bones

REBOA Zone 1 = supraceliac (abd/pelvic bleeding); Zone 3 = infrarenal (pelvic only)

Damage control orthopedics = ex-fix in stage 1, ORIF later

Vascular shunts = temporize major artery injury (e.g., Pruitt-Inahara in popliteal/femoral)

Open abdomen → ABThera vac dressing is standard temporary closure

Abdominal compartment syndrome = bladder pressure >20 + new organ dysfunction → decompressive laparotomy

Post-splenectomy vaccinations = pneumococcal, meningococcal (ACWY + B), Hib, annual flu

Perimortem C-section within 4 minutes of maternal arrest at ≥20–24 weeks

DDAVP = uremic platelet dysfunction

4-factor PCC beats FFP for warfarin reversal in major bleeding

Andexanet alfa = apixaban/rivaroxaban reversal; idarucizumab = dabigatran

Base deficit >6 in trauma predicts increased transfusion and mortality

Lactate clearance of 50% in 6 h = adequate resuscitation

MELD >20 + emergency laparotomy = ~50% mortality

Enteroatmospheric fistula = exposed bowel in granulating open abdomen wound — feared complication

Planned ventral hernia repair at 6–12 months

OPSI = overwhelming post-splenectomy infection — encapsulated organisms, 50% mortality

CRASH-2 trial = evidence base for TXA in trauma

Board pearl: "Restore physiology, not anatomy" is the single sentence summarizing the entire damage control philosophy — operate to stop death, not to fix everything.

Board Question Stem Patterns

— A 28-year-old man with multiple GSW to the abdomen has been in the OR for 75 minutes. Core temp 34.5°C, pH 7.15, INR 1.8. He has received 12 units PRBC. Surgeon notes diffuse oozing from raw surfaces. Best next step?

— Answer: Abbreviated laparotomy with packing and temporary abdominal closure, transfer to ICU for resuscitation

— Trauma patient 2 hours after MVC with class III shock — give TXA. Trauma patient 4 hours after injury — do not give TXA (may increase mortality)

— Hypotensive blunt trauma patient with positive FAST → OR, not CT

— Post-DCS ICU patient with distended abdomen, oliguria, peak airway pressures rising, bladder pressure 28 mmHg → decompressive laparotomy

— Elderly trauma patient on warfarin with INR 3.5 and intracranial/intra-abdominal hemorrhage → 4-factor PCC + vitamin K, not FFP first

— 28-week pregnant woman post-MVC, hypotensive → resuscitate mother aggressively, left lateral tilt, fetal monitoring; Rh-negative → RhoGAM

— Patient one year post-traumatic splenectomy presents with fever and chills → bacteremia from encapsulated organism; obtain blood cultures, start ceftriaxone empirically; reinforce vaccination status

— Polytrauma patient with femur fracture and unstable physiology → external fixation initially, definitive ORIF after physiologic resuscitation

— Unstable trauma patient with mangled lower extremity and SFA injury → temporary vascular shunt in stage 1, definitive bypass in stage 3

— Patient with self-inflicted GSW survives — must still report to law enforcement per state statute even with patient objection

Stem 1 — The lethal triad trigger:

Stem 2 — TXA timing:

Stem 3 — Positive FAST disposition:

Stem 4 — Abdominal compartment syndrome:

Stem 5 — Anticoagulant reversal:

Stem 6 — Pregnant trauma:

Stem 7 — Post-splenectomy:

Stem 8 — Damage control orthopedics:

Stem 9 — Vascular shunt:

Stem 10 — Mandatory reporting:

Board pearl: When the stem includes lethal triad parameters or refractory bleeding despite aggressive resuscitation, the answer is almost always damage control / temporary closure / ICU resuscitation, not "continue definitive repair" or "give more crystalloid."

Key distinction: "Stable vs unstable" is the recurring discriminator — stable patients get imaging and definitive care; unstable patients get FAST and OR.

One-Line Recap

Rapid recap bullets:

Damage control surgery is a staged strategy that abbreviates the index operation to control hemorrhage and contamination, restores physiology in the ICU, and returns for definitive repair — prioritizing survival of physiology over completeness of anatomy.

Triggers — hypothermia <35°C, acidosis pH <7.2, coagulopathy INR >1.5, transfusion >10 units, operative time >90 min in unstable patient, or anticipation of these.

Three stages — (1) OR: hemorrhage control, contamination control, temporary closure; (2) ICU: rewarm, correct acidosis and coagulopathy, monitor for ACS; (3) OR: definitive repair within 24–48 h.

Resuscitation principles — MTP 1:1:1, TXA within 3 hours, permissive hypotension (except TBI), avoid crystalloid, replace ionized calcium, warm aggressively, TEG/ROTEM-guided component therapy.

Complications to anticipate — abdominal compartment syndrome, enterocutaneous/enteroatmospheric fistula, intra-abdominal abscess, ventral hernia, VTE, AKI, OPSI after splenectomy.

Special situations — anticoagulant reversal (4F-PCC for warfarin, andexanet/PCC for Xa inhibitors, idarucizumab for dabigatran); pregnant patient gets left lateral tilt and aggressive maternal resuscitation; elderly on beta-blockers have masked tachycardia — trust lactate and base deficit.

Discharge essentials — post-splenectomy vaccinations, VTE prophylaxis, planned hernia repair at 6–12 months, PTSD screening, injury-prevention counseling, structured handoff at every transition.

Step 3 management: When the simulated patient develops the lethal triad intraoperatively, the correct order set is: pack, temporary abdominal closure, transfer to ICU, continue MTP, warm, correct coags, q1–2h ABG/lactate/iCal, plan return to OR in 24–48 hours, monitor bladder pressure — restore physiology before chasing anatomy.