Identification and Evaluation of the Indications for Use of Damage Control Surgery and Damage Control Interventions in Civilian Trauma Patients

Although damage control (DC) surgery may improve survival in select, severely injured patients, the procedure is associated with significant morbidity, and therefore should only be used when appropriately indicated. The objective of this thesis was to identify and evaluate candidate indications for use of DC surgery and DC interventions in civilian trauma patients. We conducted a scoping review to identify candidate indications. Among 27,732 citations identified by the search, we included 270 articles that reported 1,107 indications for DC surgery and 424 indications for 16 DC interventions. We conducted a content analysis to synthesize these indications into 123 named, content-characteristic codes representing unique indications for DC surgery and 101 codes representing unique indications for DC interventions. An international panel of trauma surgery experts (n=9) subsequently assessed 101 (82.1%) of the coded indications for DC surgery and 78 (77.2%) of the coded indications for DC interventions to be appropriate. We conducted a systematic review to identify studies reporting data on the reliability or validity of indications or that assessed outcomes associated with utilization of an indication or indications or the conduct of DC versus definitive surgery for one or more indications. Among 31,014 citations identified, we included 36 studies that evaluated 79 unique indications. Of these, 19 had evidence of face validity or predictive criterion validity, six had evidence supporting that they were associated with improved survival when utilized or when DC was conducted instead of definitive surgery, and three had evidence suggesting that they were associated with reduced survival which may be improved with DC surgery. Finally, we conducted a cross-sectional survey of trauma centers and surgeons located in the United States, Canada, and Australasia. In total, 232 (64.8%) trauma centers responded. These centers nominated 366 surgeons to survey about indications for DC surgery, of whom 201 (56.0%) responded. Respondents assessed 15 (78.9%) preoperative and 23 (95.8%) intraoperative indications to be appropriate. The list of candidate indications for use of DC surgery and DC interventions identified in this thesis may provide a practical foundation to guide surgical practice while studies are conducted to evaluate their impact on patient outcomes.