A Review of “Predicting the Need to Pack Early for Severe Intra-abdominal Hemorrhage” (1996)

Abstract

As highlighted by this literary Festschrift, the contributions by J. David Richardson MD to the surgical literature are substantial. While some surgeons have curriculum vitae with more publications, few academic surgeons can match the depth, breadth, and impact on the practice of surgery of the articles produced by Dr Richardson over the course of his 40+ year career. As first a medical student and then a surgical resident at the University of Louisville, where Dr Richardson spent his entire faculty career, I learned very quickly that the first step in investigating any topic in general, vascular, or thoracic surgery began with finding out what Dr Richardson had already written on the subject. His articles summarized the critical issues of the topic, cited the important previous work of others, provided practical advice, and were prescient in describing future directions in the field. The article highlighted in this review is an excellent example of a work fulfilling all those characteristics. While damage control surgery and hemostatic resuscitation may seem like elementary concepts to trauma surgeons today, it is worth remembering that their role as widely accepted principles of trauma care is a relatively recent phenomenon. Packing of wounds and traumatic injuries is not a new concept. Packing for hepatic injuries was described in the late 19th and early 20th centuries, but the technique at that time was far different than what most surgeons think of or utilize today. Prior to the 1950s, packing for hepatic trauma referred to using gauze dressing material or iodoform gauze inserted into the liver injury. This material, sometimes sutured in place, was usually left for prolonged periods of time before being gradually withdrawn at the bedside over the course of days to weeks through a separate stab incision in the abdominal wall. This technique fell out of favor following World War II and was eventually discarded due to high rates of bleeding associated with delayed pack removal, increased perihepatic infection, and the high mortality rate. Through the mid to late 20th century, improvements in civilian prehospital care and methods of patient transport, recognition of the importance of fluid resuscitation in shock based on the work of the late James Carrico, Peter Canizaro, and G. Tom Shires, and the establishment of trauma systems all saved lives of injured patients and improved trauma care. These evolutions in trauma care, however, also contributed to the development of new clinical problems for trauma surgeons. Aggressive crystalloid fluid resuscitation contributed to the development of the acute respiratory distress syndrome as well as dilutional coagulopathy and hypothermia. It was eventually recognized that operating in the face of coagulopathy was far from ideal and was associated with significant mortality. This clinical reality led some surgeons to hypothesize that perihepatic and/or intraabdominal packing, used as a temporary maneuver with planned early reoperation to remove the packs, could be useful and avoid the problems seen with prolonged intrahepatic packing that had led to its prior abandonment. A number of reports described this method for terminating the trauma laparotomy once surgical bleeding had been controlled but a coagulopathy had developed and then packing the area of continued nonsurgical coagulopathic bleeding with laparotomy pads. The coagulopathy was then corrected in the intensive care unit (ICU) with plasma transfusions to replace clotting factors, platelets, and packed red blood cells as needed. The term “damage control” was subsequently adopted to describe this process. The mortality rate for this approach initially remained high with many patients exsanguinating in the operating room or ICU when these techniques were applied late or after the patient had already developed irreversible shock.