Damage control laparotomy in exsanguinating trauma — FFICM MCQ

Correct answer: E — Pack, control contamination and transfer to ICU for correction of physiology

The correct answer is E, pack, control contamination and transfer to ICU for correction of physiology. This man has the lethal triad of hypothermia (34.2C), severe metabolic acidosis (pH 7.12, lactate 9.8 mmol/L) and coagulopathy (INR 2.1 despite massive transfusion), predicting exponentially rising mortality the longer surgery continues. Damage control surgery is indicated: rapid haemorrhage control (liver packing), limitation of bowel contamination, and temporary abdominal closure, followed by ICU transfer for rewarming, correction of acidosis and reversal of coagulopathy before returning to theatre for definitive repair. This staged approach interrupts the cycle in which ongoing operative time itself worsens hypothermia and coagulopathy, and is the standard recommended in UK major trauma pathways. Definitive repair is deferred, not abandoned. Why the other options are wrong: B, perform definitive reconstruction of every injury immediately: prolonging surgery with the lethal triad present drives further hypothermia, acidosis and coagulopathy, worsening rather than treating the underlying physiological failure. C, close the abdomen tightly to prevent heat loss: tight closure of a swollen, contaminated abdomen risks abdominal compartment syndrome and does not address ongoing coagulopathy or contamination; laparostomy or temporary closure is used instead. D, stop transfusion until INR normalises: withholding blood products in an actively bleeding, coagulopathic patient worsens haemorrhagic shock; coagulopathy is corrected with targeted component therapy via the massive transfusion protocol, not by withholding transfusion. E, give crystalloid-dominant resuscitation: large crystalloid volumes dilute clotting factors and worsen acidosis and coagulopathy, whereas balanced blood product ratios are used as part of damage control resuscitation. Key point: when the lethal triad of hypothermia, acidosis and coagulopathy is present, damage control surgery (control bleeding and contamination, then ICU resuscitation before definitive repair) takes priority over completing definitive surgery in one sitting.

Reference: NICE Guideline NG39, Major trauma: assessment and initial management (2016, updated), Recommendations on damage control resuscitation and surgery, https://www.nice.org.uk/guidance/ng39