Report on Damage Control Resuscitation

Hemorrhage accounts for 30% to 40% of trauma fatalities and is the leading cause of preventable death in trauma. Patients sustaining life-threatening trauma present with the lethal triad of acidosis, hypothermia, and coagulopathy following massive hemorrhage progressing to hemorrhagic shock, the conventional resuscitation measures focus on controlling hemorrhage, reversal of acidosis and preventing hypothermia and resuscitating with Massive transfusion of >10 units packed red blood cells [PRBCs] over 24 hours. This approach has been modified with current research taking into account Acute Traumatic Coagulopathy which had previously been attributed to resuscitation associated coagulopathy following studies showing coagulopathy at the time of presentation even prior to any resuscitation measures. This approach of damage control resuscitation has allowed for the reassessment of the resuscitation techniques of trauma patients.

Coagulopathy significantly affects resuscitation outcomes. Hemodilution as a consequence of crystalloid resuscitation was previously considered to be the major cause of acute coagulopathy associated with trauma. In trauma patients, several etiologies for coagulopathy have been identified, acidosis, hypothermia, hemodilution due to fluid or component blood product administration, disseminated intravascular coagulation (DIC) and Acute Traumatic Coagulopathy (ATC, also referred to as trauma-induced coagulopathy, trauma associated coagulopathy or acute coagulopathy of trauma.). Damage Control Resuscitation focuses on early, aggressive management of the components of the lethal triad, hypothermia, coagulopathy, and acidosis in conjunction with the damage control surgery.

Damage control resuscitation principles begin in the prehospital phase or emergency department phase of care and should be applied throughout all phases of damage control. Studies of severe hemorrhage following injury have demonstrated the survival benefit of a 1:1:1 ratio of plasma,
packed red blood cells, and platelets. This can be attributed to mitigation of the coagulopathy of trauma by the early administration of fresh frozen plasma and platelets. Furthermore, studies have found an overall detrimental effect to the use of large volumes of crystalloid fluid administration with increases in acute lung injury, acute kidney injury, duration of mechanical ventilation, length of stay, and possibly mortality.

This strategy is initiated in the ER and continues through the OR and ICU until the resuscitation is complete. Recent studies have also been evaluating the Prehospital initiation of Damage control resuscitation using plasma or whole blood. This approach aims to arrest hemorrhage by preventing iatrogenic coagulopathy, improving outcomes of damage control surgery, introducing the concept of permissive hypotension, and initiating early transfusion of FFP: RBC in 1:1 ratio.