The use of surgical damage control tactics in the treatment of severely wounded with combat abdominal trauma in modern warfare

Abstract

Objective. To analyse the results of the implementation of surgical damage control tactics in the treatment of severely wounded patients with combat abdominal trauma in an intense military conflict in terms of reducing the incidence of complications and mortality. Materials and methods. The results of treatment of 259 severely wounded with combat abdominal trauma, who underwent surgical control of injuries, were analysed. All the wounded were men, their average age was (32 ± 3.2) years. General clinical parameters, markers of sepsis and coagulogram, electrolyte and alkaline–base blood composition were determined for all wounded. Ultrasound examination of the chest and abdominal cavities was performed according to the FAST protocol, multislice computed tomography and radiographic examination of the head, chest and abdominal cavities, pelvis, electrocardiography and thromboelastography were performed as indicated. The criteria used to determine the use of surgical control of injuries were as follows: level of consciousness (stunning, sopor, coma), body temperature less than 35 °C, Algover shock index greater than 1.0, blood saturation less than 85%, positive abdominal ultrasound according to the FAST protocol. In accordance with the tactics of surgical control of injuries, the scope of "reduced" laparotomy (first stage) in severely injured combat abdominal trauma patients included bleeding control, control of intestinal contamination and temporary wound closure, the second stage included haemostatic resuscitation, correction of acidosis, hypothermia and coagulopathy, and the third stage included preparation for final reconstructive surgery. Results. Among 259 severely injured patients with combat abdominal trauma, 26 (10.0%) were delivered in a critical state of clinical death, and underwent left–sided resuscitative thoracotomy with temporary clamping of the descending aorta and direct heart massage as the first stage of treatment in the antishock ward of the emergency department. In 12 (46.2%) patients, after effective resuscitation with the restoration of cardiac activity, a midline laparotomy with resuscitative abdominal polytamping was performed. The average time to evacuate the victim from the moment of injury was (32 ± 4) minutes. In the diagnostic department, the wounded were examined and referred to the operating department. The average time from delivery to the stage of care to surgical intervention was (25 ± 5) minutes. In 92% of patients, a total midline laparotomy was used for abdominal access, which allowed for a quick examination of all parts of the abdominal cavity and pelvis. The use of modern coagulators in the "cutting" and spray coagulation modes ensured both bloodless and fast surgical access without wasting time to stop bleeding from the surgical wound.  A total of 691 abdominal injuries were diagnosed in the study patients. The first stage of surgical control of injuries was completed by temporary closure of the abdominal access, which took (85 ± 2.2) minutes. Achievement of sufficient physiological parameters allowed the interval between the first and second stages to be minimised to 24–36 hours. The third stage on average lasted (92 ± 3.2) min. Complications developed in 16.3% of severely wounded with combat abdominal trauma. The postoperative mortality rate was 10.4%. Conclusions. The use of surgical control of injuries in severely wounded with combat abdominal trauma at levels of medical care that are as close as possible to the focus of sanitary losses, subject to clearly defined indications for staged treatment and its scope, can reduce the incidence of postoperative complications to 16.3% and mortality to 10.4% (for this category of wounded, the literature reports an average mortality rate of 31% and complication rate of 39–43%).