Damage Control Resuscitation: Restarting the Machinery of Life

Abstract

Resuscitation of the patients suffering major haemorrhage has seen a marked change in mind-set in the current millennium. This article contains a perspective on the history of shock, the detrimental effects of the traditional sequential resuscitation reactive approach of using clear fluids for volume expansion followed by blood and component therapy, and the current philosophy of the early proactive transfusion of red blood cells, plasma, and platelets in a recommended ratio. The debate concerning pharmacological intervention for fibrinolysis and percutaneous mechanical control of haemorrhage will be discussed. Although the initial goal should be to achieve a ratio of 1:1:1 for packed red blood cells, plasma, and platelets, thromboelastometry is an essential point of care tool to determine the need for and effect of component therapy. This point of care tool is superior to the traditional laboratory assessment of coagulation. The use of tranexamic acid has come into question with the discovery of fibrinolytic shutdown and the detrimental effects on physiological fibrinolysis. The benefit of mechanical control of haemorrhage using percutaneous aortic occlusion is debatable. Major haemorrhage remains the commonest potentially correctable cause of early in-hospital death following major trauma. Minimising the use of clear resuscitative fluids and the early use of blood and component therapy is essential to maximise oxygen delivery, reverse the oxygen deficit and debt, and correct the coagulopathy of trauma and shock. The optimal ratio remains elusive but should be guided by thromboelastometry which will also dictate the need for antifibrinolytic therapy. The benefit and extent of permissive hypotension in those with ongoing haemorrhage until surgical control of haemorrhage can be obtained is unclear. The use of endovascular balloon occlusion of the aorta is controversial. Throughout resuscitation and damage control surgery, hypothermia must be corrected by core rewarming. Commensurate with damage control resuscitation is damage control surgery, the two being complementary for maximal benefit.