Neuro damage control: current concept and civilian applications

Volume 69, Issue 6, November 2023, 101505

Author links open overlay panel, , , , , , Abstract

Damage control (DC) initially referred to abbreviated (<1 h) surgical procedures to control abdominal hemorrhage in severe trauma patients, to avoid the ‘bloody vicious circle’ of hypothermia-coagulopathy-acidosis-hypocalcemia. Progressively, the concept was extended to pre-hospital and peri-operative surgical and non-surgical trauma care. The DC strategy can be applied either in a single severe trauma patient at risk of progression toward the bloody vicious circle or in case of limited or overwhelmed health resources (deprived environment, mass casualties, etc.).

DC strategies in neurological casualties have improved over the last decade in military neurosurgeons, but remain poorly codified in civilian settings. In this comprehensive review, we summarize the current concept of neuro-DC, which includes surgical and medical care for neurological injuries as part of a DC strategy. Neuro-DC basically consists in: (i) preventing secondary brain injury; (ii) controlling intracranial bleeding; (iii) controlling intracranial pressure; (iv) limiting contamination of compound wounds; and (v) achieving secondary anatomical restoration.

Section snippetsCurrent concept of damage control

The high mortality among wounded soldiers, as well as severely injured civilian patients, follows a tri-modal distribution: 60% occur pre-hospital, 30% within the first hours after hospital admission, and 10% within the following days. This mortality is mainly attributed to uncontrollable hemorrhage, respiratory distress, and neurological damage [1]. The classic strategy for these patients focuses on providing definitive emergent surgery after quick resuscitation. However, this strategy is

Management of war-related neurological casualties: the emergence of neuro DC

DC neurosurgery is a relatively recent concept developed in the 2000s, referring to the specific surgical management of neurotrauma within the DC strategy. The majority of data on DC neurosurgery have been published by military teams, who have gained extensive experience in managing traumatic brain injuries (TBI) under conditions of urgency, hostile environments, and limited resources. Following the standards of the North Atlantic Treaty Organization (NATO), the management of combat-related

Civil applications

Civil applications of DC in neurologically injured patients have been sparsely reported. The concept of DC in neurosurgery was initially introduced by Rinker et al. [14] who proposed training non-neurosurgeons in basic craniotomy techniques to treat TBI patients in remote Australian centers lacking neurosurgical capabilities. While Rubiano et al. claimed to be the first to use the term "neurosurgical damage control" [15], the first published description of DC neurosurgery came from Rosenfeld,

The role of neurosurgeon in DC strategy

Søvik et al. demonstrated a significant improvement in the prognosis of severely injured patients when there is increased neurosurgical involvement in trauma care [63].

In addition to their operative role in DC, neurosurgeons can also serve as advisors. They can provide remote guidance to non-neurosurgeons performing neurosurgical procedures or assist in the triage of patients with neurological injuries, working alongside the trauma leader. Trauma neurosurgeons should actively participate in

Conclusion

Following recent major terror attacks in France (Paris, 2015 and Nice, 2016), special efforts have been made to train civilian surgeons in the management of severe exsanguinating casualties. However, their knowledge and skills in DC surgery remain inadequate, irrespective of their surgical specialty [65]. Excluding neurosurgical centers in major cities, particularly within the USA, that routinely encounter ballistic head injuries, the majority of civilian neurosurgeons have limited exposure to

Author contributions

Conceptualization: RM, AD; Writing - original draft preparation: RM; Writing - review and editing: RM, CJ,BB, XJT, OM, JSD, AD; Supervision: RM.

References (65)L. Bissoni et al.REBOA as A bridge to brain CT in A patient with concomitant brain herniation and haemorrhagic shock - A case report

Trauma Case Rep

(2022)

J. Eaton et al.Outcomes following exploratory burr holes for traumatic brain injury in a resource poor setting

World Neurosurg

(2017)

S. Søvik et al.Sudden survival improvement in critical neurotrauma: an exploratory analysis using a stratified statistical process control technique

Injury

(2014)

B.J. Eastridge et al.Death on the battlefield (2001-2011): implications for the future of combat casualty care

J Trauma Acute Care Surg

(2012)

M.F. Rotondo et al.“Damage control”: an approach for improved survival in exsanguinating penetrating abdominal injury

J Trauma

(1993)

T.J. KellyDamage Control

(1944)

R. Dulou et al.The French mobile neurosurgical unit

Neurosurg Focus

(2010)

B. Malgras et al.Damage control: concept and implementation

J Visc Surg

(2017)

N.R. Langan et al.Changing patterns of in-hospital deaths following implementation of damage control resuscitation practices in US forward military treatment facilities

JAMA Surg

(2014)

D.J. Roberts et al.Evidence for use of damage control surgery and damage control interventions in civilian trauma patients: a systematic review

World J Emerg Surg

(2021)

US Department of Health and Hyman Services, Centres for disease control and prevention, N. C. for T. I. P. and C....P.A. StanworthA century of British military neurosurgery

J R Army Med Corps

(2016)

R.S. Bell et al.Joint Trauma System Clinical Practice Guideline: Neurosurgery and Severe Head Injury (CPG ID: 30)

(2017)

Bell RS, McCafferty R, Shackelford S, Tomlin J, Dirks M, Neal C. Emergency life-saving cranial procedures by...C.F. Rinker et al.Emergency Craniotomy in a Rural Level III Trauma Center

(1998)

A.M. RubianoNeurological Surgery Program Reviews: Surgical Management of Head Trauma in Simón Bolivar Hospital

(2004)

Kunth et al. 2005. Guidelines for Field Management of Combat-Related Head Trauma. Brain Trauma Fondation Guidelines....T.S. Jeong et al.Comparison of outcomes at trauma centers versus non-trauma centers for severe traumatic brain injury

J Korean Neurosurg Soc

(2022)

A. Sellier et al.Emergency cranial surgeries without the support of a neurosurgeon: experience of the French military surgeons

Mil Med

(2022)

J.E. Cohen et al.Prognosis and clinical relevance of anisocoria-craniotomy latency for epidural hematoma in comatose patients

J Trauma

(1996)

S.A. Shackelford et al.Association of time to craniectomy with survival in patients with severe combat-related brain injury

Neurosurg Focus

(2018)

I. Roberts et al.Tranexamic acid to reduce head injury death in people with traumatic brain injury: the CRASH-3 international RCT