7.21 and PTT >70 is associated with near certain mortality. 4.Initial resuscitation should begin in the emergency department and continue in the operating room following correction of deficit and using a massive transfusion program as indicated. B.DCS operative principles 1.The goal of DCS is a short operating time, followed by transport to an intensive care unit. 2.Control of hemorrhage a.Ligation of named vascular structures may be necessary and/or temporary vascular clamps may be used. b.Vascular shunting may be employed in extremities using surgical shunts, such as a Javid shunt or large-bore IV tubing. c.Abdominal packing: packs are inserted into the right upper quadrant, left upper quadrant, and pelvis. The bowel should be separated from laparotomy pads. 3.Control of contamination a.Bowel injuries may be quickly closed or resected with stapled ends left in discontinuity. b.Delay definitive repair of injury including time-consuming anastomoses and ostomies. 4.Prevent hypothermia. a.Warm operating room. b.All resuscitation fluids and blood products must be warmed to 38.0o C or higher. c.Continuous use of convective warming devices (e.g., Bair huggers) 5.Temporary abdominal closure (TAC) a. Allows "easy access" for planned next operative intervention b. At Parkland Memorial Hospital, the "Vac-Pack" dressing is employed by packing the abdomen with laparotomy pads separated from the bowel with a fluid-impervious layer (e.g., a "bogota bag or bowel bag). TAC dressing-specific drains are then placed in the packing, and a seal is created over the wound with the use of Ioban dressing. These drains are then connected to wall suction. (Note: Commercially available dressings have been made that accomplish the same goal with less "improvisation" but they are not as cost-effective.) c. Additional abdominal drains may be used as well. d. Because of its ease of application, the Vac-Pack dressing allows bedside changes in the intensive care unit. 6. Angiography/embolization a. If pelvic bleeding is suspected, the patient may be transferred to the angiography suite at this time. Significant hepatic parenchymal hemorrhage may also be controlled with angiography. C. Restoration of homeostasis in the intensive care unit 1. Rewarming a. Warm room temperature and other convective measures of warming, such as warming blankets and lamps, are used to maintain body temperature >35o C. b. Use of fluid warmer for administration of resuscitative crystalloids and blood products is mandatory. c. Continuous arteriovenous rewarming (CAVR) is occasionally performed when body temperature is less than 35o C. 2. Careful fluid resuscitation a. Resuscitation may be guided by early use of a pulmonary artery catheter. b.If massive bleeding resumes, the patient is returned emergently to the operating room for cessation of likely surgical bleeding. c.Avoid over-resuscitation. d.Monitor bladder pressure. Bladder pressures >20 mm Hg should raise concern for intra-abdominal hypertension (IAH) and >30 mm Hg for abdominal compartment syndrome (ACS). 3.Ventilatory support a.If possible, maintain tidal volumes at 6 mL/kg ideal body weight. b.If unable to oxygenate with conventinal ventilation, at Parkland Memorial Hospital we use the Volume Diffuse Respirator (VDR) as a salvage therapy. 4.Negative fluid balance a.When physiologic balance is restored, natural mobilization of third space fluids may be aided with a continuous furosemide drip, titrated to a net negative balance per hour. b.This facilitates abdominal wall closure. C.Definitive operative intervention 1. Ideally performed at 24 to 36 hours, later if indications of physiologic derangement persist 2.Removal of packs, with replacement if necessary 3.Secondary survey of the abdomen: missed injuries at the time of damage control surgery are not uncommon. 4.Restoration of gastrointestinal and vascular continuity if necessary 5.Performance of other definitive procedures, such as ostomy placement 6.Abdominal closure if possible. If bowel edema prevents this, several techniques (e.g., Wittman patch) can be employed to help reapproximate fascial edges in stages. 7.Multiple "second-looks" may be needed.">