Damage Control Surgery & Resuscitation — Abbreviated Laparotomy, Balanced Resuscitation, Open Abdomen and Timed Re-look

Blunt polytrauma, systolic 78, heart rate 132, FAST positive, lactate 7, temperature 34.6, INR 1.4 — the trauma laparotomy finds a shattered right liver lobe, a destructive sigmoid injury and a pelvis full of blood. Do you fix everything now, pack and close the skin, or pack and leave the abdomen open — what ratio of products runs while you operate, when does TXA go in, what do you check after every few units, when do you come back, and what do you tell the family about survival and hernia? The examiner will watch you abbreviate without dithering, resuscitate by ratio and clock, time packs and re-look by numbers, and defend every omission at stage 1. This page teaches each move with every number taken from the paper named beside it.^[12][13][25]

Overview & Definition — physiology first, anatomy later

Damage control surgery is abbreviated laparotomy that prioritises short-term physiological recovery over anatomical reconstruction in the seriously injured and compromised patient.^[3] It is a staged surgical approach to critically injured trauma patients, accepted yet built on limited evidence, with real concern about variable indications, rates and adverse outcomes in poorly selected cohorts.^[2] The three steps never change: an abbreviated operation, a recovering period in intensive care, and reoperation for definitive treatment — with stapled bowel and liver packing standing in for repair at stage 1, warming and clotting-factor replacement in ICU, and definitive surgery only once stability, temperature and coagulation return.^[5] Definitive surgery waits until the lethal triad of hypothermia, metabolic acidosis and coagulopathy is corrected — that wait is the whole doctrine.^[70]

Damage control resuscitation is the partner, not the synonym: hypotensive resuscitation with early blood products to prevent the triad, and crucially it may allow borderline patients who would previously have required DCS to undergo early definitive surgery as their derangement corrects sooner.^[3] The extended formulation runs six phases with DCR as phase 0 — and the same six-phase strategy now frames non-trauma abdominal emergencies, where indications are shock from uncontrolled haemorrhage or sepsis rather than injury.^[1] Non-trauma evidence stays thin: 16 studies with 455 patients, mostly retrospective series, led by uncontrolled bleeding at elective surgery, bleeding gastroduodenal ulcer disease, generalised peritonitis and mesenteric ischaemia — logical extension, careful selection.^[1]

The name is borrowed from naval practice — abbreviated initial surgical care to control bleeding and contamination in the unsalvageable-by-routine patient — and the borrowing states the priority plainly: keep the ship afloat first, rebuild cabins later.^[4] At the operation itself the aims never exceed two: control bleeding and avoid secondary contamination of the cavity.^[71] The EAST reviewers add the system moral: the open abdomen remains a heroic maneuver, and the best outcomes come from centres running a protocol for indications, temporary closure, staged reconstruction and nutrition — not from improvisation.^[6] Overuse is the examined counterweight: the overuse of damage control laparotomy is associated with increased morbidity and complications, so every indication below cuts both ways.^[7]

Indications & Patient Selection — who gets abbreviated, who gets closed

Select by physiology on admission, and the 10-year damage-control cohort hands you the panel: INR above 1.2, base deficit above 3, head AIS 3 or more, temperature below 35, lactate above 6 and haemoglobin below 7 each independently predicted early death.^[13] In that cohort 319 patients underwent damage control, 52 (16.3 percent) died early and 267 survived past 72 hours — with early deaths separated from survivors by lactate 5.81 versus 3.46, base deficit 10.10 versus 4.90 and pH 7.16 versus 7.29 on arrival.^[13] Those six thresholds plus the three admission values are the viva's expected answer to "who needs damage control" — quote them as mortality predictors, not as a validated decision rule, because no such rule sits in this pack.

For the liver specifically, pack earlier rather than repairing: packing went to the haemodynamically unstable and to haemoperitoneum above 1000 mL on imaging, and transfusion-induced coagulopathy itself was the major indication in the early packing series.^[44][42] Patterns that mandate abbreviation regardless of numbers are the ones that kill during definitive repair — major hepatic injury with coagulopathy, high-grade blunt liver trauma in the unstable patient — where packing definitively controlled bleeding in 18 of 22 patients and the four rebleeds came from hepatic artery or vein injuries needing embolisation or reoperation.^[42]

Argue the reverse direction with equal force. In secondary peritonitis the open abdomen was used in 38.0 percent of emergent laparotomies — and after propensity matching on peritonitis index, lactate and vasopressors, open-abdomen patients suffered more complications (71.2 versus 41.4 percent), higher mortality (22.5 versus 11.7 percent) and longer stay (13 versus 9 days) than primary closure.^[65] One third of those open abdomens needed multiple reoperations.^[65] Use varies more than disease does: overnight laparotomies were left open more often (42.8 versus 57.2 percent), and acute care surgeons closed primarily far less often than subspecialists (56.7 versus 78.7 percent) — so protocolised indications, consultant ownership and daylight discipline are system-level indications work.^[65]

For the septic abdomen the WSES position holds the middle: the open abdomen allows re-inspection, drainage, cytokine-loaded fluid removal and deferred anastomosis until resuscitation catches up — but it buys multiple reoperations, fistula, domain loss and hernia, so deploy it in the right patient at the right time and no other.^[62] The septic mesh-traction cohort prices that warning: 57 severely ill patients, 30-day mortality 26 percent and 2-year mortality 51 percent.^[74]

Pathophysiology — the triad, the proposed diamond, and the iatrogenic amplifiers

The vicious cycle is acidosis feeding coagulopathy feeding hypothermia feeding all three, driven by hemorrhagic shock — and the operation must stop before the irreversible stage even with organs unrepaired.^[5] Each limb has its resuscitation answer: rewarming, restrictive fluids, permissive hypotension, balanced products and protocolised massive transfusion.^[35] Calcium entered as the proposed fourth vertex because it touches every limb: hypocalcaemia has direct and indirect effects on each portion of the lethal triad, supporting its position as a fourth component of the proposed lethal diamond.^[8]

Then the viva trap springs, and the multicentre cohort is the answer: 2141 transfused severe-trauma patients, median ISS 27, 24-hour mortality 16.1 percent — with the diamond at AUC 0.71 against the triad at 0.72 (p equals 0.26), and matched Cramer's V values of 0.28 versus 0.29 — raising explicit questions about any independent early-mortality role for hypocalcaemia.^[9] That cohort defined hypocalcaemia as ionised calcium below 1.1 — the threshold to carry onto the ward round.^[9] Half of patients are already low before any blood: 189 of 370 prehospital patients (51 percent) hypocalcaemic with severe depletion under 1 percent — yet empiric prehospital calcium before transfusion is not recommended until benefit is proven.^[10] Land it as the examiner wants: monitor ionised calcium through every damage-control resuscitation, replace per protocol, but do not protocolise empiric prehospital doses and do not claim incremental prediction the cohort refuted.^[8][9][10]

The iatrogenic amplifiers are yours to prevent: prehospital teams worsen coagulopathy with excessive crystalloid and poor hypothermia prevention.^[11] The fibrinolysis limb answers to tranexamic acid, a lysine analogue that blocks plasminogen binding to fibrin — mechanism first, clock second.^[32]

Recognition & Scoring — ABC at the bedside, TRISS with humility

The ABC score uses four non-weighted, non-laboratory variables — penetrating mechanism, positive FAST, systolic at or below 90, heart rate at or above 120 — and at 2 or more it was 75 percent sensitive and 86 percent specific for massive transfusion, correctly classifying 85 percent.^[12] Its virtue is availability: no laboratory, no arithmetic, usable before bloods return. Pair it with the admission predictor panel above — INR, base deficit, head injury, temperature, lactate, haemoglobin — and you have the examined recognition set for the patient who will need abbreviation.^[13]

TRISS remains the most commonly used benchmarking tool for trauma fatality, combining anatomy, physiology, age and mechanism — and the modern story is modification plus humility.^[15] The Brazilian adjustment found original TRISS at AUC 0.90 with adjusted and novel SpO2-inclusive models all at 0.89 to 0.90 — no difference in performance.^[14] The Greek validation showed excellent discrimination (AUC 0.912, comparable to NTDB coefficients at 0.908) with poor calibration that underestimated mortality across nearly all risk groups.^[16] The Dutch all-admissions modification with sex, ASA class and nonlinear transforms reached AUC 0.915 against 0.861 for TRISS.^[18] The Spanish ICU registry found observed mortality 18 percent against predicted 16.9 with AUC 0.889.^[20] Machine learning beats it narrowly — Swedish registry XGBoost at AUC 0.91, outperforming TRISS on every tested measure — without changing bedside practice.^[19] In geriatric trauma TRISS was the strongest of the four classic scores with a mortality cutoff of 91.6 (sensitivity 97, specificity 88, AUC 0.972).^[17] Quote any of these as what they are — registry discrimination exercises — and never as permission to abbreviate or to close.

Monitoring — lactate leads, viscoelastic hype fails, calcium gets watched

Lactate outperforms base deficit at every time point that matters: initial and 24-hour lactate tracked mortality while initial base deficit did not, and the 24-hour base deficit only scraped significance.^[21] The clearance clock is the re-look clock: 10 percent died when lactate normalised within 24 hours, 24 percent when it took beyond 48, and 67 percent when it never normalised — with clearance time also tracking discharge function.^[21] Two-hour clearance adds prediction beyond admission lactate and triage scores, summarised as a fall of at least 20 percent per hour.^[22] But the single most predictive number is simpler than any formula: the repeat absolute lactate beat every clearance calculation for 24-hour death (AUC 0.85) and hospital death (AUC 0.77).^[23] For the viva: trend lactate, act on the repeat value, and never let a reassuring initial base deficit overrule a bad lactate trajectory.^[21][23]

ITACTIC is the viscoelastic verdict to memorise: 396 major-haemorrhage patients randomised to viscoelastic-augmented versus conventional-test-augmented protocols — 67 versus 64 percent alive and free of massive transfusion at 24 hours, 28-day death 25 versus 28 percent, no difference in any secondary outcome or adverse event.^[33] Candidates who claim TEG or ROTEM superiority fail the follow-up; the examined lesson is that goal-directed correction delivered late or thinly changes nothing. Watch ionised calcium through the transfusion itself — the under-1.1 threshold defines the at-risk group — without inventing a milligram dose this pack never verified.^[9] And keep fluids conservative for the open abdomen's sake: more than 5 to 10 litres within 48 hours predicted fistula, and above 10 litres predicted abscess, in the 31-study synthesis.^[60]

Damage Control Resuscitation & Transfusion — pillars, ratios, cryo and the TXA clock

The pillars, in every reviewed formulation, are the same: limit crystalloid, transfuse whole blood or balanced components toward permissive hypotension, rewarm, and stop bleeding fast.^[37] Balanced resuscitation with permissive hypotension and limited crystalloid replaced aggressive crystalloid-based care, and protocolised 1:1:1 transfusion improved morbidity and mortality in hemorrhagic shock.^[36] Plasma has replaced crystalloid as the volume expander, with goal-directed coagulopathy correction once bleeding slows — and predicting who needs the protocol remains the hard part.^[38] The MTP framing is mechanical: permissive hypotension, low-volume resuscitation, pre-emptive balanced plasma and platelets with red cells.^[39]

EAST quantified the ratio doctrine: a massive-transfusion or DCR protocol cut mortality (OR 0.61), high plasma-to-red-cell ratios cut it further (OR 0.60), high platelet-to-red-cell ratios further still (OR 0.44) — with a recommendation for high ratios of both, best achieved by transfusing equal early empiric amounts of red cells, plasma and platelets.^[25] PROPPR is the trial behind the doctrine and its honesty matters: 680 severely injured patients across 12 North American level-1 centres, 1:1:1 against 1:1:2 — no mortality difference at 24 hours (12.7 versus 17.0 percent) or 30 days (22.4 versus 26.1) — but exsanguination deaths down (9.2 versus 14.6 percent) and haemostasis achieved more often (86 versus 78 percent), with no excess across 23 prespecified complications despite more plasma and platelets transfused.^[24] Quote PROPPR as haemostasis benefit without mortality proof, and EAST as the guideline that acted on the totality anyway.^[24][25]

Cryoprecipitate earned its ratio after the 2019 Joint Trauma System guideline change: 49,301 massively transfused civilians, high cryoprecipitate-to-red-cell ratios protective at 6 hours (adjusted OR 0.52) and 24 hours (0.74), medium ratios protective at 6 hours (0.78) — independent of plasma, platelets and whole blood on sensitivity analysis.^[34]

Tranexamic acid is the clock drug of the whole topic. CRASH-2 randomised 20,211 bleeding or at-risk trauma patients within 8 hours to 1 g over 10 minutes then 1 g over 8 hours or placebo: all-cause death 14.5 versus 16.0 percent (RR 0.91), bleeding death 4.9 versus 5.7 percent (RR 0.85).^[26] The timing analysis is the examined half: treatment within 1 hour cut bleeding death (RR 0.68), 1-to-3 hours still helped (RR 0.79), and treatment after 3 hours seemed to increase bleeding death (RR 1.44) — give early or accept possible harm.^[27] The window keeps narrowing: the PATCH-Trauma analysis found benefit concentrated within 90 minutes (adjusted RR 0.64) with none beyond (adjusted RR 1.04), concluding the optimal window may sit inside 90 minutes.^[28] Causal-forest modelling of 28,448 CRASH-2 and CRASH-3 patients found the greatest relative reduction within 2 hours with rapid fall-off, and its optimal rule was treatment within 2 hours or with GCS below 9.^[29] The global prize is large: roughly 400,000 in-hospital bleeding deaths yearly, with about 128,000 avertable by TXA within the hour.^[30] Benefit ignores sex (RR 0.69 women, 0.80 men, no heterogeneity) while delivery does not — women received TXA far less often (OR 0.39), worst with age.^[31] The safety footnote stays cautious: pooled venous-thromboembolism risk 1.61 with confidence intervals crossing unity — non-significant, not exonerating.^[32] EAST conditionally recommends early in-hospital TXA for severe bleeding — conditional, early, in-hospital.^[25]

Abbreviated Techniques — packs, prudence and what stage 1 forbids

Perihepatic packing is the damage-control liver operation, and coagulopathy is its indication — packing controlled bleeding definitively in 18 of 22 complex injuries, with the four rebleeds tracing to hepatic artery or vein injuries.^[42] Timing is the examined detail and both timing studies agree: duration of packing does not drive liver or septic complications, but early removal drives rebleeding — 24-hour removal rebled more than 48-hour removal, and removal within 36 hours rebled at 21 percent against 4 percent for 36-to-72-hour removal with identical complication rates.^[40][41] So the rule: first re-look after 48 hours, packs out between 36 and 72 hours, earlier only for cause.^[40][41] Early re-laparotomy within 48 hours proved feasible in high-grade injuries with angioembolisation and aggressive transfusion on standby — with less pneumonia and ventilation, and no excess repacking or death.^[46]

Grade the honesty with the worst numbers, not the best: grade IV–V packing carried 51.3 percent mortality with 90 percent overall morbidity, and shortened packing for severe blunt injury saw 57.6 percent die, three-quarters of them within 24 hours — packing rescues the salvageable, it does not resurrect the dying.^[43][45] Stable liver injury belongs to non-operative management; the unstable patient belongs in theatre for packing — that fork, not the grade alone, is the decision.^[47] Major anatomic resections and atriocaval shunts are now redundant as emergency procedures; packing, suture, debridement and interventional radiology replaced them.^[47]

Bowel at stage 1 follows the colon evidence: primary repair of non-destructive injury leaked once in 17, while delayed anastomosis of destructive injury at re-look leaked in 5 of 20 (25 percent) — and leak killed significantly more often.^[48] Diversion matched both strategies on overall and colon-related mortality, so the examined rule is: repair what is non-destructive now, divert or delay destructive injury, and attempt delayed anastomosis only in the highly selected.^[48] Never perform destructive-injury anastomosis at stage 1 — the 25 percent leak rate is the number that fails candidates who do.^[48]

Rank temporary closure by closure, not by habit. Skin-only closure closed fascia most often — but those patients were the least injured with the lowest lactate, base deficit and transfusion burden, so quote the selection bias with the result.^[52] Among the truly open, vacuum beats Bogotá bag: ABThera vacuum associated with more fascial closure than bag, and single-centre VAC closed fascia in 6 days against 21 for bag with fewer operations, fewer complications and better survival.^[52][55] Traction beats vacuum alone: vacuum-assisted mesh-mediated traction closed 73 percent against 54.9 for bag alone, and the RCT-only meta-analysis put traction-plus-vacuum 35 points ahead of vacuum alone for definitive closure — with fewer perioperative and hospital deaths, fewer fistulae, fewer hernias and fewer abscesses across all studies.^[51][53] The Finnish multicentre cohort agrees: mesh-mediated traction cut failed-closure odds ten-fold (OR 0.1) with 30 percent overall open-abdomen mortality.^[49] Pooled traction-plus-vacuum results run 83.5 percent closure, 5.6 percent fistula, 6.2 percent planned hernia, 72 percent hospital survival — with 40.5 percent incisional hernia reminding you closure is not cure.^[54] Bogotá bag and Barker packs keep one honest advantage — cheap, available materials — against vacuum's superior fluid control and closure.^[56] The guideline synthesis lands where the numbers point: WSACS and EAST favour negative-pressure systems for superior results.^[57]

ICU Phase & Open-Abdomen Care — correct, conserve, close early

Correct the triad in order: rewarm, replace products by ratio with cryoprecipitate attention, watch ionised calcium, and ventilate the acidosis while its cause resolves — warming alone never finished the job in any cohort above.^[35][34][9] Keep resuscitation fluids conservative once bleeding stops: the fistula and abscess predictors are volume predictors, and every litre past 5 in 48 hours buys risk without benefit.^[60] Feed early where feasible — enteral nutrition within 24 to 48 hours may support fascial approximation, and its absence with organ dysfunction, infection, re-explorations and fistula is what delays definitive closure.^[64][60] Aim closure within 5 to 7 days: early fascial closure means fewer complications, especially fistula.^[64]

The open abdomen is now standard care in damage control, intra-abdominal hypertension and severe sepsis — and it creates the problems it solves: severe fluid and protein loss, nutritional failure, fistula, retraction with domain loss, and massive hernia — which is why early definitive closure is the prevention for all of them.^[61] The early course runs on loss and support: fluid and electrolyte loss, ventilation need, nutrition need.^[63] Angiography slots into stage II beside packing, not instead of it — embolisation rescued packed rebleeders and underwrote the feasible early re-look cohort.^[42][46]

Re-look & Reconstruction — physiology sets readiness, the clock sets the odds

Readiness is lactate behaviour, not elapsed hours: operate definitively when lactate normalises and physiology steadies — 10 percent mortality inside 24-hour normalisation against 67 percent when it never normalises.^[21] But the closure odds decay with every takeback, so do not confuse readiness with leisure: SLEEP-TIME's 368 multicentre patients closed fascia in 92.9 percent at a mean 61 hours over 1.6 re-laparotomies — each extra re-laparotomy cut closure odds by 91.5 percent, and first takeback beyond 24 hours collapsed the odds stepwise (down 78 percent at 24 to 36 hours, 91 percent at 36 to 48, 98 percent past 48).^[50] The rule the examiner wants: first re-laparotomy within 24 hours, minimum number of takebacks, closure at the earliest physiologically honest moment.^[50]

Planned versus on-demand relaparotomy changes less than doctrine suggests: 162 developing-world patients showed no difference in open abdomen at discharge, stay, morbidity or mortality — planned brought shorter intervals but more ICU, on-demand brought worrying delays.^[66] For mesenteric ischaemia the second look is conceptually mandatory — extent of resection cannot be judged once — with planned, on-demand, open and laparoscopic modes all still argued.^[67] At re-look, sequence matters: washout, pack removal, vascular control, bowel decision by the colon rules above, then closure attempt with escalating traction — and a bridging mesh that accepts a planned hernia beats a forced closure that fistulises, with 40 percent of mesh-implantation septic cases ending bridged rather than closed.^[74][48]

Complications & Pitfalls — the priced list

Price the open abdomen with three audits. Johannesburg: 205 mostly penetrating patients, 26.8 percent dead — a third of deaths in day 1, 40 percent across days 1 to 7 — with haemodynamic instability, hypothermia, coagulopathy, massive transfusion, vasopressors and associated injuries driving death, and fistula in 7.3 percent, surgical-site infection in 45.3 percent, ventral hernia in 10.2 percent among morbidities.^[59] Finland: 676 patients, 30 percent dead, multiorgan dysfunction and age predicting death, high-volume centres protective.^[49] Secondary peritonitis, matched: open abdomen 71.2 percent complications and 22.5 percent mortality against 41.4 and 11.7 for primary closure.^[65] Fistula specifics: 14 percent after vacuum laparostomy, with preoperative lactate above 3.5 carrying odds of 12.41 — and pooled traction-plus-vacuum fistula at 5.6 percent.^[58][54]

Compartment syndrome after primary closure has exactly one level-I answer: documented abdominal compartment syndrome gets decompressive laparotomy — which is simultaneously the prevention argument for leaving the abdomen open in the first place.^[6] Frozen abdomen and domain loss come from retraction left too long; the mitigation is the SLEEP-TIME rule above, not a better mesh.^[62][50] The 31-study synthesis names the modifiable predictors: failed closure, large-bowel resection and big early fluids predict fistula; day-5-or-later closure plus anastomosis predicts leak; large-bowel resection plus big fluids predicts abscess.^[60] Technique pitfalls close the list: packs become sepsis when left, NPWT without traction closes less, and the unnecessary open abdomen harms matched patients — overuse is a complication of judgement, not of material.^{[40][53][65][7]}

Burns are the grimmest subgroup and the viva's edge case: 38 burned patients opened, compartment syndrome the indication in 82 percent, fascial closure achieved in a minority of survivors, in-hospital mortality 68 percent.^[72] Quote it when asked who dies despite perfect technique.

Prognosis & Disposition — what survival costs

Contemporary damage-control survival is better than its reputation and worse than complacency: 16.3 percent early death in the 319-patient series, with the admission panel above separating the dying from the salvageable.^[13] Age is the great modifier that is not a veto: over-55 damage-control mortality ran 29.4 against 4.8 percent (adjusted OR 7.09), and damage-control laparotomy 55.6 against 7.1 — yet both age groups carried massive transfusion burdens with comparable stays and complications, and most elderly patients survived: support the intervention in the severely injured elderly, and say so explicitly.^[68] Children with firearm abdominal injury did strikingly well once past the bay: 13 percent overall mortality, all but one death in bay or theatre, every damage-controlled child surviving to discharge — with longer stays and more infections as the price.^[69] Early cryoprecipitate ratios move the needle inside day 1; closure technique echoes for years through hernia clinics — 40.5 percent incisional hernia even after traction-plus-vacuum success.^[34][54] Disposition honestly: rehabilitation for the deconditioned, nutrition rebuilding for the fistula-free, hernia repair planning for the closed-with-tension, and stoma decisions owned at re-look, not deferred.^[48][54]

Special Populations — same doctrine, shifted emphasis

• Children: compensated shock fools, hypothermia threatens, and the firearm pattern dominates — but damage control laparotomy performed in 16 percent of paediatric laparotomies matched primary closure on readmission and mortality.^[69]
• Elderly: vital signs mislead while transfusion need does not — 19 versus 15 units across age groups — with the 29.4 percent mortality honestly quoted beside the survival majority.^[68]
• Burns: compartment syndrome first, trauma second; closure rare, death common at 68 percent — open only for compartment syndrome or catastrophe, never for convenience.^[72]
• Septic and peritonitis abdomens: matched harm against primary closure, 38 percent open rates, overnight and operator variation — protocolise, consultant-own, and re-ask at every takeback whether closure is possible today.^[65]
• Mesenteric ischaemia: the non-trauma second-look paradigm — resect dead bowel, leave doubtful bowel, return by plan — with the mode still debated.^[67]
• Resource-limited settings: the adapted vacuum dressing cut nursing burden and lifted delayed primary closure where commercial systems were unaffordable — technique follows physics, cost follows context.^[73]

Evidence, Guidelines & Regional Differences — who proved what, where

EAST (US, 2017) owns the ratio doctrine and the open-abdomen damage-control review with its single level-I decompression recommendation; PROPPR (North America, 12 centres, 2015) owns the honest null behind it; CRASH-2 and its timing analysis (40 countries, 2010–2011) own the TXA clock, refined by PATCH-Trauma and causal-forest modelling; ITACTIC (Europe, 2021) owns the viscoelastic null; SLEEP-TIME (EAST registry, 15 centres) owns the closure clock; the Finnish multicentre cohort, the Johannesburg audit and the Greys Hospital relaparotomy comparison own the southern-hemisphere reality check.^{[25][6][24][26][27][33][50][49][59][66]} WSES owns the septic open-abdomen position; the 2019 Joint Trauma System DCR update owns the cryoprecipitate ratio now validated in 49,301 civilians.^[62][34] Regional practice differs in blood-product availability, vacuum-system access and ICU capacity — the trial numbers travel, the implementation adapts, and the low-resource vacuum experience proves adaptation can still close abdomens.^[73]

Exam Pearls — the one-liners that score

• Triad versus diamond: hypothesis from calcium physiology, refutation from 2141 patients at AUC 0.71 versus 0.72 — monitor ionised calcium, withhold empiric prehospital doses.^[8][9][10]
• Recognition: ABC 2 or more (75/86), admission six-predictor panel, lactate 5.81 versus 3.46 separating early deaths from survivors.^[12][13]
• TRISS family: original 0.90, Greek 0.912 with poor calibration, Dutch 0.915 versus 0.861, RETRAUCI 0.889, geriatric cutoff 91.6, XGBoost 0.91 — discrimination without calibration is decoration.^{[14][16][18][20][17][19]}
• Lactate clock: 10/24/67 percent by normalisation time; repeat absolute beats clearance maths; 2-hour clearance adds value at minus 20 percent per hour.^[21][22][23]
• PROPPR: null mortality, fewer exsanguinations (9.2 versus 14.6), more haemostasis (86 versus 78) — quote all three or quote nothing.^[24]
• EAST: protocol OR 0.61, high plasma 0.60, high platelets 0.44 — empiric 1:1:1, conditional early TXA.^[25]
• TXA: 1 g plus 1 g; ≤1 h RR 0.68, 1–3 h 0.79, >3 h RR 1.44; 90-minute and 2-hour refinements; 128,000 avertable deaths; women equally helped, half as treated.^{[26][27][28][29][30][31]}
• Packs: coagulopathy indication, 48-hour first look, 36-to-72-hour removal (21 versus 4 percent rebleed early), ≤48-hour re-laparotomy feasible with embolisation cover.^{[42][40][41][46]}
• Closure: skin-only if least injured, vacuum over bag (6 versus 21 days), traction over vacuum (plus 35 points RCT, 73 versus 54.9, ten-fold Finnish odds), pooled 83.5 percent with 5.6 fistula.^{[52][55][53][51][49][54]}
• Re-look: lactate readiness, ≤24-hour first takeback, minus 91.5 percent odds per extra laparotomy, planned-versus-demand equivalence, colon leak 25 percent punishing stage-1 anastomosis.^{[21][50][66][48]}
• Harm profile: matched OA 71.2 versus 41.4 complications and 22.5 versus 11.7 death; EAF 14 percent with lactate-3.5 odds 12.41; burns 68 percent dead.^[65][58][72]
• Extremes: elderly 29.4 versus 4.8 but not futile; paediatric firearm DCL all survived; cryo high ratio halves 6-hour odds.^[68][69][34]

Revision summary

Damage control is physiology-first staged surgery — abbreviated operation, ICU restoration, planned definitive repair, optionally six phases from DCR at phase 0 — offered to the patient whose admission panel (INR, base deficit, head injury, cold, lactate, anaemia) predicts early death, and withheld where primary closure wins, because matched peritonitis data punish the unnecessary open abdomen — while resuscitation runs limited crystalloid, balanced products at EAST ratios with PROPPR honesty and cryoprecipitate attention, TXA at 1 g plus 1 g inside 90 minutes to 2 hours and never late, lactate trends timing the re-look, packs staying 36 to 72 hours with first look after 48, colon destructive injury diverted rather than anastomosed at stage 1, vacuum with mesh-mediated traction closing fascia toward 83 to 93 percent when the first takeback lands inside 24 hours and takebacks stay few, fistula-compartment-hernia priced honestly, the elderly and children treated on the same doctrine with age-quoted outcomes, and every number above traceable to the paper beside it.^{[3][13][65][25][24][34][26][21][40][48][53][50][68][69]}

References74ShowHide

1. [1]Weber DG, Bendinelli C, Balogh ZJ Damage control surgery for abdominal emergencies. Br J Surg, 2014.PMID 24273018
2. [2]Benz D, Balogh ZJ Damage control surgery: current state and future directions. Curr Opin Crit Care, 2017.PMID 29035926
3. [3]Lamb CM, MacGoey P, Navarro AP, et al. Damage control surgery in the era of damage control resuscitation. Br J Anaesth, 2014.PMID 25038156
4. [4]Annecke T, Tjardes T, Limper U, et al. [Damage Control Resuscitation and Damage Control Surgery]. Anasthesiol Intensivmed Notfallmed Schmerzther, 2024.PMID 38914077
5. [5]Parreira JG, Soldá S, Rasslan S [Damage control: a tactical alternative for the management of exanguinating trauma patients]. Arq Gastroenterol, 2002.PMID 12778312
6. [6]Diaz JJ Jr, Cullinane DC, Dutton WD, et al. The management of the open abdomen in trauma and emergency general surgery: part 1-damage control. J Trauma, 2010.PMID 20539186
7. [7]Chung CY, Scalea TM Damage control surgery: old concepts and new indications. Curr Opin Crit Care, 2023.PMID 37861194
8. [8]Wray JP, Bridwell RE, Schauer SG, et al. The diamond of death: Hypocalcemia in trauma and resuscitation. Am J Emerg Med, 2021.PMID 33421674
9. [9]Dupuy C, Martinez T, Duranteau O, et al. Comparison of the lethal triad and the lethal diamond in severe trauma patients: a multicenter cohort. World J Emerg Surg, 2025.PMID 39773274
10. [10]Brandt MD, Liccardi C, Heidle J, et al. Prevalence of Trauma-Induced Hypocalcemia in the Prehospital Setting. J Spec Oper Med, 2023.PMID 37094288
11. [11]Friedman J, Ditzel RM Jr, Fisher AD Coagulopathy Associated With Trauma: A Rapid Review for Prehospital Providers. J Spec Oper Med, 2022.PMID 35649406
12. [12]Nunez TC, Voskresensky IV, Dossett LA, et al. Early prediction of massive transfusion in trauma: simple as ABC (assessment of blood consumption)? J Trauma, 2009.PMID 19204506
13. [13]Frischknecht A, Lustenberger T, Bukur M, et al. Damage control in severely injured trauma patients - A ten-year experience. J Emerg Trauma Shock, 2011.PMID 22090736
14. [14]Domingues CA, Coimbra R, Poggetti RS, et al. New Trauma and Injury Severity Score (TRISS) adjustments for survival prediction. World J Emerg Surg, 2018.PMID 29541155
15. [15]Schluter PJ The Trauma and Injury Severity Score (TRISS) revised. Injury, 2011.PMID 20851394
16. [16]Filippatos G, Tsironi M, Zyga S, et al. Validation of the Trauma and Injury Severity Score for Prediction of Mortality in a Greek Trauma Population. J Trauma Nurs, 2022.PMID 35007249
17. [17]Javali RH, Krishnamoorthy, Patil A, et al. Comparison of Injury Severity Score, New Injury Severity Score, Revised Trauma Score and Trauma and Injury Severity Score for Mortality Prediction in Elderly Trauma Patients. Indian J Crit Care Med, 2019.PMID 31086450
18. [18]Driessen MLS, van Klaveren D, de Jongh MAC, et al. Modification of the TRISS: simple and practical mortality prediction after trauma in an all-inclusive registry. Eur J Trauma Emerg Surg, 2022.PMID 35182160
19. [19]Holtenius J, Mosfeldt M, Enocson A, et al. Prediction of mortality among severely injured trauma patients A comparison between TRISS and machine learning-based predictive models. Injury, 2024.PMID 38936227
20. [20]Chico-Fernández M, Llompart-Pou JA, Sánchez-Casado M, et al. Mortality prediction using TRISS methodology in the Spanish ICU Trauma Registry (RETRAUCI). Med Intensiva, 2016.PMID 27068001
21. [21]Husain FA, Martin MJ, Mullenix PS, et al. Serum lactate and base deficit as predictors of mortality and morbidity. Am J Surg, 2003.PMID 12727572
22. [22]Régnier MA, Raux M, Le Manach Y, et al. Prognostic significance of blood lactate and lactate clearance in trauma patients. Anesthesiology, 2012.PMID 23168430
23. [23]Dezman ZDW, Comer AC, Smith GS, et al. Repeat lactate level predicts mortality better than rate of clearance. Am J Emerg Med, 2018.PMID 29544906
24. [24]Holcomb JB, Tilley BC, Baraniuk S, et al. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. JAMA, 2015.PMID 25647203
25. [25]Cannon JW, Khan MA, Raja AS, et al. Damage control resuscitation in patients with severe traumatic hemorrhage: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg, 2017.PMID 28225743
26. [26]Shakur H, Roberts I, Bautista R, et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet, 2010.PMID 20554319
27. [27]Roberts I, Shakur H, Afolabi A, et al. The importance of early treatment with tranexamic acid in bleeding trauma patients: an exploratory analysis of the CRASH-2 randomised controlled trial. Lancet, 2011.PMID 21439633
28. [28]Ali A, Gruen RL, Bernard SA, et al. Tranexamic Acid Timing and Mortality Impact After Trauma. Ann Emerg Med, 2026.PMID 40751727
29. [29]Osawa I, Goto T, Roberts I Tranexamic acid for trauma: optimal timing of administration based on the CRASH-2 and CRASH-3 trials. Br J Surg, 2025.PMID 40277024
30. [30]Ker K, Kiriya J, Perel P, et al. Avoidable mortality from giving tranexamic acid to bleeding trauma patients: an estimation based on WHO mortality data, a systematic literature review and data from the CRASH-2 trial. BMC Emerg Med, 2012.PMID 22380715
31. [31]Nutbeam T, Roberts I, Weekes L, et al. Use of tranexamic acid in major trauma: a sex-disaggregated analysis of the Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage (CRASH-2 and CRASH-3) trials and UK trauma registry (Trauma and Audit Research Network) data. Br J Anaesth, 2022.PMID 35597623
32. [32]Nishida T, Kinoshita T, Yamakawa K Tranexamic acid and trauma-induced coagulopathy. J Intensive Care, 2017.PMID 28729903
33. [33]Baksaas-Aasen K, Gall LS, Stensballe J, et al. Viscoelastic haemostatic assay augmented protocols for major trauma haemorrhage (ITACTIC): a randomized, controlled trial. Intensive Care Med, 2021.PMID 33048195
34. [34]Hynes AM, Cannon JW, Yan R, et al. Do not forget the cryoprecipitate: The impact of the 2019 Joint Trauma System Damage Control Resuscitation Clinical Practice Guideline on mortality. J Trauma Acute Care Surg, 2026.PMID 41589734
35. [35]Kaafarani HM, Velmahos GC Damage Control Resuscitation In Trauma. Scand J Surg, 2014.PMID 24777616
36. [36]Cantle PM, Cotton BA Balanced Resuscitation in Trauma Management. Surg Clin North Am, 2017.PMID 28958369
37. [37]Kalkwarf KJ, Cotton BA Resuscitation for Hypovolemic Shock. Surg Clin North Am, 2017.PMID 29132511
38. [38]Chang R, Holcomb JB Optimal Fluid Therapy for Traumatic Hemorrhagic Shock. Crit Care Clin, 2017.PMID 27894494
39. [39]Young PP, Cotton BA, Goodnough LT Massive transfusion protocols for patients with substantial hemorrhage. Transfus Med Rev, 2011.PMID 21664104
40. [40]Nicol AJ, Hommes M, Primrose R, et al. Packing for control of hemorrhage in major liver trauma. World J Surg, 2007.PMID 17334868
41. [41]Caruso DM, Battistella FD, Owings JT, et al. Perihepatic packing of major liver injuries: complications and mortality. Arch Surg, 1999.PMID 10487590
42. [42]Krige JE, Bornman PC, Terblanche J Therapeutic perihepatic packing in complex liver trauma. Br J Surg, 1992.PMID 1737272
43. [43]Di Saverio S, Catena F, Filicori F, et al. Predictive factors of morbidity and mortality in grade IV and V liver trauma undergoing perihepatic packing: single institution 14 years experience at European trauma centre. Injury, 2012.PMID 22281197
44. [44]Paydar S, Mahmoodi M, Jamshidi M, et al. Perihepatic Packing versus Primary Surgical Repair in Patients with Blunt Liver Trauma; an 8-year Experience. Bull Emerg Trauma, 2014.PMID 27162877
45. [45]Martellotto S, Melot C, Raux M, et al. Depacked patients who underwent a shortened perihepatic packing for severe blunt liver trauma have a high survival rate: 20 years of experience in a level I trauma center. Surgeon, 2022.PMID 34154925
46. [46]Kang BH, Jung K, Choi D, et al. Early re-laparotomy for patients with high-grade liver injury after damage-control surgery and perihepatic packing. Surg Today, 2021.PMID 33170365
47. [47]Badger SA, Barclay R, Campbell P, et al. Management of liver trauma. World J Surg, 2009.PMID 19760312
48. [48]Oosthuizen G, Buitendag J, Variawa S, et al. Penetrating colonic trauma and damage control surgery: Anastomosis or stoma? ANZ J Surg, 2021.PMID 34056835
49. [49]Rasilainen S, Mentula P, Salminen P, et al. Superior primary fascial closure rate and lower mortality after open abdomen using negative pressure wound therapy with continuous fascial traction. J Trauma Acute Care Surg, 2020.PMID 32701909
50. [50]Kwon E, Krause C, Luo-Owen X, et al. Time is domain: factors affecting primary fascial closure after trauma and non-trauma damage control laparotomy (data from the EAST SLEEP-TIME multicenter registry). Eur J Trauma Emerg Surg, 2022.PMID 34845499
51. [51]Pillay P, Smith MTD, Bruce JL, et al. The Efficacy of VAMMFT Compared to 'Bogota Bag' in Achieving Sheath Closure Following Temporary Abdominal Closure at Index Laparotomy for Trauma. World J Surg, 2023.PMID 36995399
52. [52]Hu P, Uhlich R, Gleason F, et al. Impact of initial temporary abdominal closure in damage control surgery: a retrospective analysis. World J Emerg Surg, 2018.PMID 30237824
53. [53]Cristaudo A, Jennings S, Gunnarsson R, et al. Complications and Mortality Associated with Temporary Abdominal Closure Techniques: A Systematic Review and Meta-Analysis. Am Surg, 2017.PMID 28228207
54. [54]Petersson P, Petersson U Dynamic Fascial Closure With Vacuum-Assisted Wound Closure and Mesh-Mediated Fascial Traction (VAWCM) Treatment of the Open Abdomen-An Updated Systematic Review. Front Surg, 2020.PMID 33251242
55. [55]Yanar H, Sivrikoz E Management of open abdomen: single center experience. Gastroenterol Res Pract, 2013.PMID 24348537
56. [56]Ribeiro Junior MA, Barros EA, de Carvalho SM, et al. Open abdomen in gastrointestinal surgery: Which technique is the best for temporary closure during damage control? World J Gastrointest Surg, 2016.PMID 27648164
57. [57]Afsar L, Capelli PC, Carvalho G, et al. Narrative Review of Open Abdomen Management and Comparison of Different Temporary Abdominal Closure Techniques. J Abdom Wall Surg, 2025.PMID 40556709
58. [58]Giudicelli G, Rossetti A, Scarpa C, et al. Prognostic Factors for Enteroatmospheric Fistula in Open Abdomen Treated with Negative Pressure Wound Therapy: a Multicentre Experience. J Gastrointest Surg, 2017.PMID 28536807
59. [59]van der Merwe E, Moeng MS, Joubert M, et al. The mortality rate of patients with open abdomen and contributing factors - a three-year audit in a major academic trauma unit. S Afr J Surg, 2023.PMID 37791710
60. [60]Cristaudo AT, Jennings SB, Hitos K, et al. Treatments and other prognostic factors in the management of the open abdomen: A systematic review. J Trauma Acute Care Surg, 2017.PMID 27918375
61. [61]Demetriades D, Salim A Management of the open abdomen. Surg Clin North Am, 2014.PMID 24267502
62. [62]Sartelli M, Abu-Zidan FM, Ansaloni L, et al. The role of the open abdomen procedure in managing severe abdominal sepsis: WSES position paper. World J Emerg Surg, 2015.PMID 26269709
63. [63]Farach S, Ghneim MH, Bruns B, et al. Complications of damage-control abdominal surgery: What you need to know. J Trauma Acute Care Surg, 2025.PMID 40802495
64. [64]Kňazovický M, Kováč I, Romžová B, et al. Contemporary management of the open abdomen: standards, challenges, and future directions. Langenbecks Arch Surg, 2026.PMID 42120816
65. [65]Kao AM, Cetrulo LN, Baimas-George MR, et al. Outcomes of open abdomen versus primary closure following emergent laparotomy for suspected secondary peritonitis: A propensity-matched analysis. J Trauma Acute Care Surg, 2019.PMID 31045736
66. [66]Scriba MF, Laing GL, Bruce JL, et al. The Role of Planned and On-Demand Relaparotomy in the Developing World. World J Surg, 2016.PMID 27160454
67. [67]Meng X, Liu L, Jiang H Indications and procedures for second-look surgery in acute mesenteric ischemia. Surg Today, 2010.PMID 20676851
68. [68]Lustenberger T, Talving P, Schnüriger B, et al. Impact of advanced age on outcomes following damage control interventions for trauma. World J Surg, 2012.PMID 22037692
69. [69]Gilna GP, Saberi RA, Ramsey W, et al. Outcomes of Abdominal Firearm Injury and Damage Control Laparotomy in the Pediatric Population. J Surg Res, 2022.PMID 35940049
70. [70]Lee JC, Peitzman AB Damage-control laparotomy. Curr Opin Crit Care, 2006.PMID 16810046
71. [71]Rodrigues RR, Carmona MJ, Junior JO Bleeding and damage control surgery. Curr Opin Anaesthesiol, 2016.PMID 26934280
72. [72]Hardin MO, Mace JE, Ritchie JD, et al. An experience in the management of the open abdomen in severely injured burn patients. J Burn Care Res, 2012.PMID 22777397
73. [73]Campbell AM, Kuhn WP, Barker P Vacuum-assisted closure of the open abdomen in a resource-limited setting. S Afr J Surg, 2010.PMID 21542399
74. [74]Käser SA, Brosi P, Clavien PA, et al. Blurring the boundary between open abdomen treatment and ventral hernia repair. Langenbecks Arch Surg, 2019.PMID 30729317