Patient selection: Damage control approach is clearly not benign as it commits the patient to multiple operations, prolonged sedation and mechanical ventilation, and repeated administration of general anesthesia. It also increases the risks related to leaving the body cavities open, including infections, fluid and heat loss, excessive metabolic demands, loss of domain (e.g., large hernia), and organ injury (e.g., enteric fistulae). Thus, it must be applied in a group of patients where the risk-to-benefit ratio justifies this approach. Equally important is to make the decision early in the course of the operation. Choosing to apply damage control strategies too late in the operation is equally harmful. You must identify the presence of hypothermia, acidosis, and coagulopathy early in the course. Often labeled the “lethal triad,” these factors perpetuate one another, creating a vicious cycle that is difficult to interrupt. Late coagulopathy often reflects dilution of platelets, hemoglobin, and clotting factors, but early coagulopathy is a well-recognized marker of injury severity – its presence associated with significantly greater mortality. Similarly, hypothermia is not only due to loss of body heat and drop in temperature due to infusion of cold fluids, but more importantly, it reflects presence of significant tissue ischemia. Maintaining normal body temperature is an energy-dependent process that patients in shock are unable to maintain. Acidosis reflects the presence of shock, which in turn further perpetuates coagulopathy and hypothermia. Thus, the surgeon must actively monitor the patient for the development of these markers and use their presence as a trigger to switch into a damage control mode. There are no universally agreed-upon criteria, but a reasonable list would include core temperature <35 °C, a base deficit >10 mmol/L, requirement for vasoactive agents to maintain a systolic blood pressure >90 mmHg, a pH less than 7.20, transfusion of >10 units of packed red blood cells, and clinical evidence of coagulopathy/diffuse oozing. Experienced trauma surgeons know that it is better to avoid development of the lethal triad rather than to reverse it, because by the time all these signs become obvious, it may already be too late. If you are not sure, it is better to err on the side of being too cautious and opt for a damage control approach. Remember that you can always come back to fight another day if the patient survives today.

Basic goals: The major aim during the initial operation is to control the bleeding as soon as possible to minimize the blood loss and limit the duration of shock. As time is of critical importance, the quickest exposure should always be selected. Thus, laparoscopic or minimally invasive approaches are not appropriate for patients where every minute counts. Once in the body cavity, tools that can expedite controlling the source of bleeding should be liberally used. For example, a stapler fired through a tract of a bullet is a fast way to open the track and expose the bleeding vessels in the lung. When the source of bleeding is exposed, consider ligation if it can be done without excessive morbidity. If ligating the blood vessel is likely to result in significant tissue loss, select a temporary shunt instead of a formal anastomosis/graft, which should be delayed for a later stage. When unable to get quick exposure of the blood vessel, which is not uncommon in the head and neck region, consider tight packing with or without balloon tamponade (e.g., Foley catheter) of the tract as a damage control strategy. Similarly, for nonvascular injuries (e.g., solid organs, pelvic fractures, mangled extremities), packing combined with rapid inflow control could be lifesaving. Always remember that saving life takes priority over saving organs or limbs, and doing a quick, focused operation is better than doing a perfect operation that takes too long.