Damage control resuscitation: how to use blood products and manage major bleeding in trauma

Abstract

Exsanguination comprises 30% to 40% of mortality in trauma and is the leading cause of trauma mortality in civilian and military populations. Many different strategies have been suggested for the management of haemorrhage, but recently damage control resuscitation (DCR) and damage control surgery (DCS) have become mainstays of treatment. The main principles of DCR are permissive hypotension as well as prevention of the ‘lethal triad’ of acidosis, coagulopathy and hypothermia. Acidosis affects multiple physiologic processes as well as worsening coagulopathy. Hypothermia can worsen acidosis and cause coagulopathy. DCR is designed to prevent the lethal triad by minimizing crystalloid administration and providing a balanced blood product resuscitation in a 1:1:1 ratio of red cells:plasma:platelets to mimic whole blood. Adjuncts such as cryoprecipitate and tranexamic acid are frequently required, and their use may be guided by new coagulation tests including thromboelastography (TEG) and rotational thromboelastometry (TEM).DCS is used to complement DCR. DCS focuses on rapid and immediate repairs including control of haemorrhage, temporary repair of hollow viscus injuries and packing to control non‐surgical bleeding. The patient is then transferred to the intensive care unit (ICU) and undergoes further resuscitation with DCR for the treatment of coagulopathies and metabolic derangements. Once the patient is adequately resuscitated, they are then taken back to the operating room for definitive surgery. DCR and DCS utilizations have improved outcomes for trauma patients, but further research is needed to continue to decrease preventable mortality from haemorrhage in the severely injured trauma patient.