Damage control resuscitation in patients with major trauma: prospects and challenges

Abstract

: Trauma is the leading cause of death for younger ages across the world, with acute traumatic hemorrhage one of the main reasons of trauma mortality. In the last decade trauma resuscitation has significantly evolved away from the era of massive crystalloid transfusion where the endpoint was to keep a normal perfusing volume. A better understanding of homeostatic mechanisms of hemostasis, and of the systemic inflammatory and counter-inflammatory response syndromes gave birth to damage control and hemostatic resuscitation. Modern trauma resuscitation aims to control the lethal triad of coagulopathy, hypothermia and acidosis with the understanding that any deregulation from the steady state will lead to a cascade of adverse events. This review paper analyzes the latest evidence-based concepts of trauma resuscitation. These new strategies are the early transfusion of blood products in a ratio of ≤2:1:1 [packed red blood cells (PRBCs): fresh frozen plasma (FFP): platelets], the warming of the patient and of the administered fluids, the intravenous administration of 1 g of tranexamic acid (TXA) within 3 h of injury and then infusion of another 1 g for 8 hours, the use of viscoelastic hemostatic assays (VHAs) for optimization of the transfusion strategy, the minimization of active bleeding through permissive hypotension, and the early bleeding control with mechanical, interventional and surgical methods. Emphasis is placed in the evidence supporting each one of these interventions, and their application during the different stages of trauma care, from the prehospital to the hospital setting.