Damage Control Resuscitation

Author: Brad Kinney MD, Emergency Medicine Physician. December 15, 2018.

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BLUF

• Damage Control Resuscitation (DCR) is the modern, multidisciplinary management approach to the severely injured trauma patient.
• DCR comprises two main management approaches: Hemorrhage Control and Hemostatic Resuscitation.

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Background

Damage Control Resuscitation (DCR) is the modern, multidisciplinary management approach to the severely injured trauma patient that focuses on the aggressive correction of metabolic derangements and limited, staged surgical interventions. The term “damage control” originates from a practice in the US Navy where the crew of a catastrophically damaged ship performs limited repairs to vital systems that allow the ship to continue functioning and fighting until it eventually returns to the shipyard for definitive repair. Similarly, in the 1980s, surgeons progressively adopted a practice of initial, limited surgical repair of catastrophically injured patients with subsequent definitive operative repair when physiologically capable.

“Multiple trauma patients are more likely to die from their intra-operative metabolic failure than from a failure to complete operative repairs.”

-Karim Brohi

This practice, labeled “Damage Control Surgery (DCS),” offered a significant survival benefit but also introduced significant morbidity; a morbidity only mitigated by trauma resuscitation extending outside of the operating room to involve a diversity of specialties and a variety of novel concepts and interventions. This novel, modern, more comprehensive approach to trauma resuscitation was renamed “Damage Control Resuscitation.”

Massive traumatic hemorrhage ignites a deadly synergistic triangle of hypothermia, acidosis, and coagulopathy. Exsanguination leads to hemorrhagic shock and the decreased perfusion of vital tissues thus worsening acidosis and hypothermia. Both hypothermia and acidosis amplify the coagulopathy of trauma through complex mechanisms but essentially by creating a dysfunctional and dysregulated coagulation cascade. Each factor in the the lethal triad feeds the other which then exacerbates the exsanguination that initiated the process. Without rapid intervention and careful resuscitation, the lethal triad leads to inevitable demise. 

DCR aggressively fights to reverse this downward spiral with two essential concepts: Hemorrhage Control and Hemostatic Resuscitation. “External hemorrhage control” is achieved prehospital and in emergency rooms with direct pressure, pressure dressings, tourniquets, hemostatic gauze, and other mechanical adjuncts until “internal hemorrhage control” can be achieved in the operating room via DCS. “Hemostatic resuscitation” spans care from the point of injury to the ER, the OR, and the ICU by applying the principles of hypotensive resuscitation, balanced transfusions, and limited crystalloid while administering tranexamic acid and actively preventing hypothermia.

Trauma resuscitation has evolved immensely over the last two decades and still continues to rapidly evolve. The previous routine practice of large volume crystalloid infusions, rapid normalization of blood pressure parameters, and massive transfusions with only red blood cells has proven harmful and the exact opposite of what is truly beneficial in trauma resuscitation. In another twenty years, we may look back on our current DCR practices in shame, but until then, we will relentlessly pursue the truth and practice medicine the best we can in light of the current evidence. Future posts will further explore, distill, and explain the evidence supporting the current principles integral to Damage Control Resuscitation.

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Podcast

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Intel

1. King DR. Initial Care of the Severely Injured Patient. N Engl J Med. 2019 Feb 21;380(8):763-770. PMID: 30786189.
2. Ball CG. Damage Control Resuscitation: history, theory and technique. Canadian Journal of Surgery, 2014. PMID: 24461267.
3. Mizobata, Y. Damage control resuscitation: a practical approach for severely hemorrhagic patients and its effects on trauma surgery. Journal of Intensive Care, 2017. Accessed 15DEC2018, Open Access.
4. Brohi, Karim. Damage Control Surgery. trauma.org, 2000. Accessed 15DEC2018.
5. Damage Control Resuscitation. Joint Trauma System Clinical Practice Guideline. 03 February 2017. Accessed 15DEC2018, DCR JTS CPG.