Indications to perform damage control surgery in pediatric trauma: a scoping review-Are children little adults?

Abstract

Background: Damage Control Surgery is a technique aimed at reducing mortality in trauma patients, but its use in pediatric patients lacks standardized indications. Proper patient selection is essential to mitigate morbidity associated with Damage Control Surgery.

Objective: This review aims to clarify the reported indications for Damage Control Surgery in pediatric trauma patients.

Methods: A systematic search of PubMed and Embase was conducted without publication year restrictions to identify studies reporting indications for performing Damage Control Surgery in pediatric trauma patients. Backward citation analysis was performed on identified review articles that were excluded. Indications or patient characteristics guiding surgical decision-making in the emergency department were extracted and categorized.

Results: Forty studies were included: 25 case reports, 13 case series, and 2 observational studies. The case reports and case series involved 98 patients with 368 reported indications, with severe trauma (26.1%), hemodynamic instability (18.2%), and radiological or clinical evidence of severe hemorrhage or contamination (28.2%) being the most observed. The observational studies found a higher Injury Severity Score, lower systolic blood pressure, decreased Glasgow Coma Scale, lower body temperature, and more frequent blood transfusions in the Damage Control Surgery groups compared to the control groups.

Conclusions and relevance: Severe trauma, hemodynamic instability, and injuries related to severe hemorrhage or contamination emerged as key indications for Damage Control Surgery in pediatric trauma, consistent with findings in adult trauma populations. However, the lethal triad of acidosis, hypothermia and coagulopathy was infrequently reported as a primary indication for Damage Control Surgery in children. This may reflect the greater compensatory capacity of pediatric patients, potentially delaying the manifestation of these physiological derangements. Our findings suggest that early intervention with Damage Control Surgery in cases of severe trauma, exsanguination, gross contamination, and hemodynamic instability may help prevent the progression to critical physiological states such as the lethal triad. This underscores the importance of timely recognition and intervention in pediatric trauma management.

Keywords: Damage control intervention; Damage control surgery; Indication; Lethal triad; Pediatric; Scoping review; Trauma.

Fig. 1

Pathophysiology of trauma. Trauma leads to both significant blood loss and an inflammatory response, resulting in shock with hypotension and poor tissue perfusion. This progresses to the lethal triad of coagulopathy, hypothermia, and acidosis, with the latter two exacerbating coagulopathy. Various iatrogenic factors can worsen this process (e.g., cold fluids, cold environment, transfusion ratios, sedation). Coagulopathy represents the final endpoint, leading to a vicious cycle with increased hemorrhage and worsening of coagulopathy

Fig. 2

Flowchart of study selection

Fig. 3

Recommendation for a practical guideline. This figure is based on the results, literature regarding the pathophysiology of trauma, and expert opinion from pediatric and trauma surgeons, pediatric intensivists, and pediatric anesthesiologists. DCS should be considered in the presence of severe trauma, hemodynamic instability, or clinical or radiological evidence of severe hemorrhage or contamination. Waiting for the presence of physiological parameters of the lethal triad is discouraged; however, if present, these factors serve as aggravating factors and should prompt immediate action. Direct definitive surgery can be justified when all the aforementioned factors are absent. Because of the risk of significant morbidity, it is important to keep reassessing whether the Damage Control approach remains justified as the patient’s clinical condition evolves. Abbreviations: AIS, Abbreviated Injury Scale; DCS, Damage Control Surgery; GA, Gustilo–Anderson; HD, Hemodynamic; ISS, Injury Severity Score